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* lots of questions from classified section of this
 #173146  
  anothergoljafan - 03/22/07 14:12
 
  SN Questions
1- 57 y/o male is on hemodialysis for CRF. Which of the ffg metabolic derangements can be anticipated?
A- hypercalcemia
B- hypophosphatemia
C- osteomalacia
D- Vit. D excess
E- Hypoparathyroidism

Answer is c- osteomalacia.
Kidneys failure to excrete phosphate àhyperphosphatemia & fail to synthesize 1,25(OH)2D3. then Vit. D def. àimpaired intestinal ca absorption.
Phosphate retention, defective intestinal absorption & skeletal resistance to PTH à hypocalcemia à secondary hyperparathyroidism à worsens hyperphosphatemia by increasing the Ph. release from boneà renal osteodystrophy



2- 50 y/o woman with a Hx of essential HTN, presents to ER with severe headache, nausea, vomiting and photophobia. On P/E, BP= 160/100 mmHg, she’s confused with nuchal rigidity without focal neurologic signs.
** What’s the Dx?
A- hemorrhagic stroke
B- ruptured cerebral aneurysm
C- meningitis
D- ischemic cerebrovascular accident
E- TIA


** Dx is best confirmed with?
A- LP
B- Doppler US of carotid artries
C- Head MRI
D- Head CT followed by cerebral angiography
E- EEG


** What’s the next most important step in Mx?
A- urgent surgery with aneurysm clipping
B- admission to ICU, close monitoring and Tx of HTN
C- admission to ICU, close monitoring and IV antibiotics
D- anticoagulation & antiplatlete therapy
E- serial LP to drain CSF

Answers are B, D, A
most likley the pt. ruptured cerebral anurysm, as pt. is confused, no focal signs present and pt. has nuchal rigidity, could be and most likely due to the blood in the CSF--> meningeal irritation, etc..
although you also see nuchal rigidity w/ meningitis, here you have confusion as well
although they give us a nice high B.P of 160/100, and we might want to choose stroke over cerebral anurysm, given the rest of the prez. here anurysm is more likly, as well as you would expect to see neuro focal findings w/ stroke, not present here
ischemic cerebrovascular accident --> expect to see some focal signs as well as may not have nuchal rigidity
TIA, usually transient and other symptoms present , not seen here


3- During an elective laparascopic cholecystectomy, the patient developes a sudden onset drop in BP, atrial desaturation and an increase in ventilatory pressure. What’s the most appropriate step of Mx?
A- an IV fluid bolous
B- decompression of the pneumoperitoneum
C- inserting a chest tube
D- re-evaluating the position of the endotracheal tube & portable CXR
E- aborting the procedure & converting to an open cholecystectomy

Answer is C, coz patient has developed tension pneumothorax.




4- 2 wk old boy is brought for check up. He’s been doing well at home. Results of his newborn screen shows he has sickle cell dis. What’s the most important step in his Mx?
A- avoiding heat exposure
B- immunization with pneumococcal vaccine
C- folic acid supplements
D- iron supplements
E- prophylactic penicillin


** Six months later, the same patient returns with a 3 day Hx of lethargy & fever with rhinorrhea and cough. On P/E, he is pale, tacchycardic with a LUQ mass. Hgb= 4, Plt= 100000, WBC= 15000 with 50% segmented neut. , reticulocyte count=15%. What’s the Dx?
A- Acute chest syn.
B- Acute splenic sequestration
C- Aplastic crisis
D- Intussusception
E- Vaso-occlusive crisis


Answer is E & B. because he’s at high risk of infection, especially with encapsulated organisms and penicillin will dramatically decrease this risk. Pneumococcal vaccine is not effective in neonates. It’s usually given at 2 yrs age.



5- A 52 y/o man receives a preoperative evaluation before an alective surgery. He is asymptomatic with a normal P/E, but he is noted to have a Hgb= 10.8, Hct= 33, MCV= 70, RBC= 6.1x1000/ microlit. What’s the most likely Dx?
A- Sickle cell dis.
B- Iron def. Anemia
C- Alpha thalassemia major
D- Beta thalassemia minor
E- Anemia of chronic dis.

Answer is D. low MCV is either IDA or beta-thal. BUT, high no. of RBCs is characteristic of beta-thal. In IDA, RBC count is below normal.
pt. has hypocromic, microcytic anemia,..as well as increased retic. count--> increased RBC's, ..this last feature makes the better choice here to be thalassemia, as oposed to iron def. for example
iron def. seems to be avery good choice, as one should think anemia in older MAN , is due to cancer-COLON ca , until proven otherwise..however you would expect to see low reticulocytes count w/ iron def. anemia.
note- elevated retic. counts--> seen in thalassemia/hemoglobinopathy,..like SS anemia

6- match the clinical description with the most likely organism:

a- Strep. Pneumoniae
b- Staph. Aureus
c- Strep. Viridans
d- Providentia stuartii
e- Actinomyces israelii
f- Hemophilus ducreyi
g- Neisseria meningitides
h- Listeria monocytogene

1- 30 y/o female with MVP, MR develops fever, anorexia & weight loss after a dental procedure

2- 80 y/o male hospitalized for hip Fx, has foley cath. in place, develops shaking chills, fever & hypotension.

3- young man develops painless, fluctuant, purplish lesion over mandible, after several weeks cutaneous fistula is noted.

4- sickle cell patient presents with high fever, toxicity signs of pneumonia & stiff neck.


Answers:
1- c, 2- d, 3- e, 4-a





7- 65 y/o male with Hx of DM & cardiomyopathy, presents with severe knee pain. On P/E, knee is swollen, red & tender. Knee X-Ray shows linear clcification.
*** Dx is best made by:
A- Serum uric acid
B- Serum calcium
C- Arthrocentesis & identification of birefringent rhomboid crystals
D- Rheumatoid factor

*** Further workup inthis patient should include evaluation for:
A- Renal dis.
B- Hemochromatosis
C- PUD
D- Lyme dis.

Answers are C & B. Acute monoarticular arthritis in association with linear calcification in the cartilage of knee maqkes the Dx of pseudogout which is positive for birefringent crystals in joint fluid. Pseudogout maybe associated with hemochromatosis.



8- 65 y/o woman with a 12 Hx of symmetric polyarthritis, presents with splenomegaly, ulcers on lat. Malleoli, synovitis of wrists, shoulders and knees, and no hepatomegaly.
Lab results : WBC=2500, RF= 1:4096, this patients WBC diff is most likely to show what ?
A- pancytopenia
B- lymphopenia
C- granulocytopenia
D- lymphocytosis
E- basophilia

Answer is C. case of felty’s syn. ( RA+ splenomegaly+ leukopenia ), the mech. Of granulocytopenia is poorly understood.


9- A patient with low grade fever & weight loss has poor excursion on the Rt. side of chest with decreased fremitus, flatness to percussion and decreased breath sounds. Trachea is deviated to the Lt. What’s the most likely Dx?
A- Pneumothorax
B- Pleural effusion secondary to histoplasmosis
C- Consolidated pneumonia
D- Atelectasis

Answer is B. Physical findings all consistent with pleural effusion, which in large amount can shift trachea to the Lt. in pneumothorax hyperresonance of the affected side is present. Atelectasis on the Rt would shift trachea to the Rt.




10- A patient have an unexpected high value for diffusing capacity, this finding is most consistent with which of the ffg?
A- Anemia
B- Cystic fibrosis
C- Emphysema
D- Intrapulmonary hemorrhage

Answer is D. Decreased diffusing capacity is seen in: primary parenchymal disorder, anemia & removal of lung tissue.
Increased value is seen in : polycythemia, CHF & intrapulmonary hemorrhage.



11- A 65 y/o man is admitted to the hospital with anginal chest pain. His general health has been excellent, although he has had a multinodular goiter for many years. He had a series of thyroid function tests 4 weeks before admission, and the results are :
Serum T4 8.0 µg/dL
Free T4 index 8.0
Serum T3 152 ng/dL
Serum thyrotropin (TSH) 0.7 µU/mL

A MI is ruled out, but chest pain continues. A coronary arteriogram shows a 90% stenosis of the left main coronary artery. A coronary artery bypass graft is done. The patient has an uneventful postoperative course and is discharged on the seventh postoperative day. One month later, he is readmitted in atrial fibrillation with a rapid ventricular response. Repeat thyroid function testing shows the following:
Serum T4 15.0 µg/dL
Free T4 index 15.8
Serum T3 220 ng/dL
Serum TSH <0.01 mU/µL

What is the most likely Dx?
A. Graves' disease
B. Stress-induced hyperthyroidism
C. Iodine-induced hyperthyroidism
D. Silent thyroiditis
Answer is C. The natural history of multinodular goiters is slow growth and gradual decrease in thyrotropin (TSH), reflecting increasing thyroid hormone production. This progression occurs over years to decades, however. Many patients with multinodular goiters have autonomous areas within their thyroid. This patient had normal thyroid function 1 month before admission. However, his serum TSH level was near the lower limits of normal, suggesting the possibility of autonomous thyroid function.
When patients with multinodular goiters are exposed to excess iodine, severe hyperthyroidism may occur. This is known as iodine-induced hyperthyroidism or the Jod-Basedow phenomenon. When iodine supplementation is introduced into areas of iodine deficiency, iodine-induced hyperthyroidism may occur in patients with multinodular goiters. Iodine-induced hyperthyroidism may occur in nonendemic goiter areas as well, often with devastating consequences.
The high iodine content of the dye used for the cardiac catheterization undoubtedly precipitated the hyperthyroidism in this patient. The onset of hyperthyroidism may be delayed for several weeks to months after the iodide exposure.
Although other causes of hyperthyroidism are possible, none is as likely as this scenario. When patients with multinodular goiter must be exposed to excess iodine (for example, during cardiac catheterization, computed tomographic [CT] scan with contrast medium, or amiodarone therapy), premedication with antithyroid drugs (methimazole or propylthiouracil) should be considered.


12- A 43 y/o woman complains of itching that keeps her awake at night. Physical examination is normal, except for the liver, which is felt 7 cm below the right costal margin.The blood count is normal; the results of serum chemistry tests are as follows:
• Creatinine 0.8 mg/dL
• Bilirubin 0.6 mg/dL
• Alanine aminotransferase 78 U/L
• Albumin 4.2 g/dL
• Alkaline phosphatase 450 U/L
Which test would you order next in order to diagnose the underlying disorder?
(A) Serum protein electrophoresis
(B) Anti¬smooth-muscle antibody
(C) Antimitochondrial antibody
(D) Technetium-99m liver-spleen scan
(E) ERCP

Answer is C. This is the classic description of primary biliary cirrhosis. Itching is the most common specific symptom of early primary biliary cirrhosis. Approximately 70% of affected patients have enlarged livers. The best screening test for suspected primary biliary cirrhosis is the antimitochondrial antibody test. It is positive in 95% of affected patients and has a 98% specificity if newer enzyme-linked immunosorbent assay (ELISA) tests are used. Serum protein electrophoresis might show a diffuse increase in immunoglobulins. However, this finding is nonspecific and may be found in many chronic liver diseases. Anti¬smooth-muscle antibody tests are positive in some patients with autoimmune chronic hepatitis. However, the test is nonspecific and not terribly useful. The sulfur colloid technetium liver-spleen scan is useful for detecting portal hypertension and hypersplenism. However, it is not specific and would not be helpful in diagnosing primary biliary cirrhosis. Endoscopic retrograde cholangiopancreatography (ERCP) is typically normal in patients with primary biliary cirrhosis. Its only role in the diagnosis of primary biliary cirrhosis is in the patient who presents with a similar syndrome but who has a negative antimitochondrial antibody test. ERCP would then be performed to look for other causes of disease such as primary sclerosing cholangitis.



13- A patient presents to your office with complaints of severe earache and decreased hearing on the left side. Examination confirms left otitis media. You prescribe an oral cephalosporin and an analgesic. The next day the patient is brought to the emergency room with a rash and moderate bronchospasm. Reviewing his office record you are horrified to discover that he is known to have a severe allergic reaction to penicillin.
What should you tell the patient at this point?
(A) Apologize and explain what happened.
(B) Apologize and offer to compensate him financially.
(C) Attribute the rash and the bronchospasm to his infection.
(D) Explain to the patient that he is allergic to cephalosporin as well as penicillin.
(E) No explanations are necessary.
Answer is A. Medical errors are common but are infrequently reported to patients. The fear is that acknowledging a mistake may lead to litigation. Nevertheless, there is no excuse for a physician not to admit a mistake, which is an inevitable part of medical practice. Apologizing and explaining is not only ethical, but also has been shown to decrease the risk of litigation. There is no need or obligation to offer financial compensation. Trying to attribute your mistake to other causes, or attempting to blame the patient for your negligence is not only unethical, but will increase your risk of litigation. Finally, nothing will anger a patient more than no explanation at all.



14- A 29 y/o woman presents with an exacerbation of her asthma. She is 11 weeks pregnant. She has mild intermittent asthma and usually takes a ß-agonist as needed. She has one 4-year-old child who is in day care and has had a recent upper respiratory tract infection. She has a dry cough, clear nasal discharge, myalgias, and fatigue.
On physical examination, she is talking in full sentences and has normal tympanic membranes, mildly erythematous oropharynx without exudates, no adenopathy; she has positive wheezing bilaterally. The peak flow is 300 mL; her usual result is 390 mL. Pulse oximetry is 93% on room air.Which of the following is indicated in the management of this patient?
(A) Amoxicillin
(B) Theophylline
(C) Prednisone
(D) Montelukast
(E) Flunisolide
Answer is E. Treatment principles for asthma in the nonpregnant patient apply also to the pregnant patient. She has mild intermittent asthma with an exacerbation, for which therapy with an inhaled glucocorticoid is an appropriate choice. Use of inhaled glucocorticoids is safe in pregnancy.
Asthma in pregnancy has a variable course, with one third of patients getting better, one third getting worse, and one third staying the same. This patient has had mild symptoms and now has an exacerbation related either to an upper respiratory tract infection, or to worsening of her asthma because of her pregnancy. She has no signs of streptococcal pharyngitis, sinusitis, bacterial tracheobronchitis, or pneumonia; antibiotics should therefore not be given. Prednisone therapy should be reserved for further symptoms. Theophylline can be used in pregnancy with close monitoring, but it is not the next drug of choice. Montelukast may be used in pregnancy, but should be reserved for progressive symptoms.
The patient should continue therapy with ß-agonists. Use of a peak flow meter at home is integral to her management; she should be instructed and encouraged in its use.




15- A 30-year-old woman presents because of 6 months of amenorrhea. She had regular menses starting at age 13 years and is otherwise healthy. Menses gradually became irregular over the past 5 years, in spite of relatively stable weight and activity. She has no acne or hirsutism. The results of recent laboratory tests included normal serum thyroid-stimulating hormone and prolactin levels and a negative serum pregnancy test.
What is the next most useful diagnostic test for the evaluation of secondary amenorrhea in this patient?
(A) Measurement of LH
(B) Measurement of FSH
(C) Pelvic US
(D) Measurement of serum estradiol
(E) MRI of the pituitary gland
Answer is B. In this patient, the negative pregnancy test, and normal serum TSH and prolactin levels exclude the most common causes of secondary amenorrhea. The remaining causes include hypothalamic amenorrhea and ovarian failure. Of the tests listed, serum FSH is the most likely to be diagnostic of a reproductive endocrine abnormality, as it has a longer half life than luteinizing hormone and becomes elevated relatively early in the process of ovarian aging. Luteinizing hormone is less useful because of its greater variability across the normal menstrual cycle (including the dramatic, often 10-fold, increase at the mid-cycle surge), its more striking 1 to 2 hourly pulsatility, and its elevation in polycystic ovary syndrome as well as ovarian failure. Serum estradiol is frequently in the normal range in various reproductive disorders and therefore rarely useful. MRI of the pituitary gland is not indicated unless other tests are normal and a hypothalamic cause of amenorrhea needs to be ruled out. Finally, pelvic ultrasound can show the presence of ovaries, their size, and the uterine morphology and endometrial thickness, but cannot diagnose the cause of secondary amenorrhea. It may be more useful in the evaluation of primary amenorrhea, if the physical examination is inadequate to confirm the presence of intact ovaries and a uterus, or in the evaluation of excessive menstrual bleeding, when it can identify endometrial thickening, polyps, and/or uterine leiomyomas. A medroxyprogesterone challenge test can show that the uterine anatomy and vaginal outflow track are normal, which is suggested by the history of previously normal menstrual cycles. In addition, the challenge test provides some information about recent estrogen exposure. However, it cannot be diagnostic in estrogen deficiency.


16- A 2 y/o has a chronic cough. CXR reveals hyperinflation of the left hemithorax. Bilateral decubitus views showed that the right lung becomes appropriately atelectatic however, the left side shows no change in appearance with decubitus positioning. What’s the most likely diagnosis?

Asymmetric hyperinflation suggests the possibility of an aspirated foreign body in this two year old infant. These findings suggest the diagnosis of an aspirated foreign body or a possible obstruction of the left main stem bronchus from a central etiology. Bronchoscopy is both diagnostic and therapeutic.



17- match this drugs with their associated syndrome:
A- barbiturates
B- Ecstasy
C- Inhalants
D- Marijuana
E- Methamphetamine
F- PCP

1- Severe encephalopathy
2- Lung cancer
3- Rhabdomyolysis during intoxication
4- Wanting to touch/be touched during intoxication
5- Seizures during withdrawal
6- “ Swiss cheese “ appearance on functional brain imaging
A-5, B-4, C-1, D- 2, E-6, F-3


18- 72 y/o man with Hx of UTI & CHF is admitted for sepsis & pulmonary edema. He’s treated with clindamycin, tobramycin & IV furosemide. After 4 days, sepsis signs are improves but BUN= 60 & Cr.= 5 mg/dl. BP=125/75 , PR=72( no postural changes ).
1-What’s the most likely cause of his renal dysfunction?
A- Prerenal azotemia
B- ATN
C- Interstitial nephritis
D- Hypercalcemic nephropathy

2- What’s the best way to confirm the Dx?
A- Urine Na of 25 mEq/L
B- Renal tubular epithelial cells & muddy brown casts in sediment
C- Negative US
D- Abnormalities of medulla in IVP

Aswers are B & B. There’s no clinical evidence of prerenal azotemia, so the most likely Dx is ATN due to toxicity with aminoglycoside. Urine sediment in ATN is abnormal and shows renal tubular epithelial cells, debris & muddy brown casts. Since patient has been getting diuretics, high urine Na is less specific.

19- 70 y/o man with Hx of COPD, presents with worsening SOB of the last couple days. He’s coughing yellow-colored sputum and gets no result from his beta 2 agonist & ipratropium aerosolized pumps. On P/E, RR=40, HR=110, BP= 155/85, he’s afebrile and using his accessory muscles for respiration. Also inspiratory & expiratory diffuse wheezing on both sides of his lungs are heard. What’s the most likely Dx?
A- Acute exacerbation of COPD
B- Alfa-1 antitrypsin def.
C- Chronic bronchitis
D- Exacerbation of asthma
E- Pneumonia
Answer is A- Acute exacerbation of COPD, it occurs when patient develops acute onset of marked dyspnea & tachypnea with use of accessory mucles with no response to medication.


20- 73 y/o male with Hx of HTN, presents with short episode of Lt. sided weakness & slurred speech. Also he has a Hx of 3 brief episodes of sudden Rt. eye vision impairment in the last month.
1- What’s the best next diagnostic test?
A- Cerebral MRI
B- Holter monitoring
C- Visual evoked responses
D- Carotid artry doppler US
E- Conventional cerebral angiography
2- Episodes of visual loss are related to:
A- Retinal vein thrombosis
B- Central retinal A. ischemia
C- Post. cerebral A. ischemia
D- Middle cerebral A. ischemia
E- Post. ciliary A. ischemia
Answers are D & B. This is a classicd case of extracranial internal carotid A. dis. which include episodes of ipsilat. transient monocular blindness ( amaurosis fugax ) & contralat. TIA consisting of motor weekness. The most appropriate test to confirm the Dx of carotid stenosis is Doppler us. The mech. of transient monocular blindness is embolism to the central retinal A. or one of its branches.

21- A 5 y/o presents to the ER 3 h after a possible button battery ingestion. The patient is in no acute distress, vital signs are stable, and examination is benign. CXRshows what appears to be a small button battery in the stomach. Which of the following is the MOST appropriate next action?
(A) Upper GI series to further delineate the exact location of the foreign body
(B) Attempt battery removal by the Foley balloon catheter technique
(C) Immediate GI consultation for endoscopic removal
(D) Immediate surgical consultation
(E) Discharge to home with parental observation and weekly radiographs

The answer is E. Button batteries lodged in the esophagus require emergencyremoval to avoid esophageal burns and perforation. If the button battery has passed the esophagus and the patient is asymptomatic, home observation with serial x-rays toensure passage through the pylorus is the appropriate course of action. Most button batteriesthat have passed the esophagus will transit through the entire body within 24 to 48 h without difficulty. If the battery is of large diameter and the patient is younger than 6
years, the battery is less likely to pass, and endoscopic retrieval is the preferred treatment.


22- A 45 yo male with a long Hx of alcohol use and presumptive gastritis presents to the with sudden onset of severe abdominal pain and vomiting. V/S: BP=110/60, HR=110/min , T=101°F, RR= 30/minhe’s diaphoretic with epigastric tenderness and mild guarding. Lab data: WBC= 30,000, amylase =2,000. CXR shows a small amount of free air under the diaphragm. What is the MOST likely diagnosis?
(A) Acute pancreatitis with associated Mallory- Weiss syndrome
(B) Acute pancreatitis with associated Boerhaave’s syndrome
(C) Acute pancreatitis with associated enzymatic destruction of bowel wall
(D) Acute pancreatitis secondary to anterior duodenal ulcer perforation
(E) Acute pancreatitis secondary to posterior duodenal ulcer perforation

answer is E. Because the pancreas adheres to the posterior duodenum, ruptured posterior duodenal ulcers generally penetrate into the pancreas rather than perforate into the free peritoneum. Anterior ulcers are more likely to perforate into the peritoneal cavity. A Mallory-Weiss tear of the esophageal wall usually presents with
symptoms similar to reflux esophagitis and causes moderate, self-limited bleeding. Patients with Boerhaave’s syndrome rapidly deteriorate to a state of shock and septicemia
due to a malignant mediastinitis.


23- A 55 y/o male without significant medical history presents with LLQ pain and constipation. V/S: T= 100.5°F, PR= 85, BP=150/80, RR=12. P/E is unremarkable except for mild LLQ tenderness without guarding and rebound. Rectal examination shows heme-negative stool and no tenderness.Lab results are within normal limits except for WBC=13,000 with a left shift. Which of the following would be the MOST appropriate management for this patient?
(A) Prompt surgical evaluation in the ED
(B) Emergent upper GI series
(C) Emergent barium enema
(D) Discharge to home with bowel rest and oral antibiotics
(E) Discharge home with repeat abdominal examination in 12 h or sooner if worse

The answer is D. The patient described in the scenario most likely has diverticulitis. Patients with localized pain and no signs and symptoms of peritonitis or systemic infection do not require hospitalization. Outpatient management consists of bowel rest, broad-spectrum oral antibiotic therapy, and close follow-up.


24- Which of the following etiologic agents is the MOST common cause of infection in liver transplant patients?
(A) Candida
(B) Cytomegalovirus
(C) Herpes simplex virus
(D) P. carinii
(E) L. monocytogenes

The answer is B. Complications of infections in liver transplant patients account for nearly 90 percent of deaths. The most common infectious agent after transplantation is Cytomegalovirus (CMV. Reported occurrence ranges from 23 to 85 percent of all liver transplant patients. Fortunately, CMV is rarely fatal.



25- A 56 y/o heavy alcohol user male presents with vomiting blood for several hours. BP=90/60, PR=110, RR=16, and T=98°F. Placement of an NGT shows active bright red bleeding. Which of the following is the treatment of choice?
(A) Tamponade with a Sengstaken-Blakemore tube
(B) Therapeutic upper GI endoscopy
(C) Octreotide infusion
(D) Vasopressin infusion
(E) Immediate referral for surgical intervention

The answer is B. GI bleeding is a common problem seen in the ED and is potentially life threatening. For patients with significant active bleeding, emergency endoscopy is the treatment of choice. Esophageal varices can be treated endoscopically with either band ligation or sclerotherapy, resulting in control of acute bleeding in up to 90 percent of patients. Hemostasis can be achieved with nonvariceal sources of bleeding as well. Drug therapy with both octreotide and somatostatin reduces bleeding from both varices and PUD and is a useful adjunct to endoscopy. Vasopressin therapy has largely been discontinued due to a high rate of adverse effects including hypertension, arrhythmias, myocardial ischemia, and decreased cardiac output. Balloon tamponade can be used as a temporizing measure to control bleeding by placing direct pressure on the gastric and esophageal mucosa. However, it is frequently associated with complications, including mucosal ulceration, esophageal or gastric rupture, asphyxiation from dislodged balloons, and aspiration pneumonia. Although it is appropriate to make a surgeon aware of a critical patient, emergency surgical intervention is indicated only in those patients who fail endoscopic hemostasis and medical therapy.



*** 36 y/o woman with meno/metrorrhagia, inlarged uterus, which of the ffg would tell the severity of this condition?
a- CBC
b- Hysteroscopy
c- US
d- Pelvic exam

It’s US, when severity of the condn is asked, it need not necessarily mean
bleeding (submucosal and intramural) it could be pressure sym also(subserosal), hence US. to add, since 36 yr most common is fibroids since adenomyosis in the premenopausal, tho' both can have meno metrorrhagia.


*** what’s the most effective way to prevent kidney stones?
a- exercise
b- diet
c- hydration
d- periodic U/A

*** 25 y/o female G1P0, 16 wks of gestation, presents with vaginal bleeding & cramps. No products of conception is expelled yet. What’s the next step of Mx?
a- Adimt to hospital, observation & monitoring
b- Bed rest at home
c- Admit to hospital, D&C

*** Which of the ffg is a contraindication for vaginal delivery after previous c/s ?
a- Low segment transverse uterine incision
b- breech
c- clinically adequate pelvis
d- placenta previa
a. repeat cs possible, unless longitudinal incision, not done nowadays.
b. vaginal can be done.
c. prerequisit for vaginal.
d. regardless of previous delivery, since the incision would be on the low implanted placenta- torrential bleeding unless the (lower placental edge is more than 2cm from the internal os and it the first
delivery without previous CS
answer is d.

*** 23 y/o female with primary amenorrhea, on P/E breats are abesnt, but uterus is present, what test will u orderfirst ?
a- FSH
b- Karyotype
c- Testosterone
d- estrogen

FSH. Good explanation in first aid..



*** Post MI pulmonary edema, what do you do next?

reduction of pulmonary venous return (preload reduction) and reduction of systemic vascular resistance (afterload reduction) with diuretics ( furesmide ) & morphine sulfate, in a case of hypotension give inotropic agents, supplemental O2.


*** 50 y/o male with known Hx of TB, presents with shoertness of breath, CXR shows massive Rt. side pleural effusion, what’s the next step?
a- CT
b- Thoracocentesis
c- Pericardiectomy
d- etc.

b- thoracocentesis


*** in coarctation of aorta:
1- peripheral resistance a- increase b-decrease
2- pulmonary resistance a- increase b- decrease
1- decrease, 2- increase


*** to prevent hepatitis B in a IV drug abuser, what would you do?
a- HBV vaccine
b- HBV Ig
c- Both
d- etc


*** patient presents with trauma to base of neck, damage to which structure causes most severe compromise of cardiorespiratory system?
a- thoracic aorta
b- jugular vein
c- esophagus
d- SVC


19 y/o with a small lump in her Lt./ breast is very concerned that it’s malignant cancer, work up & Bx shows it’s benign, but she is still extremely worried inspite of reassurance by her physician. Which of the ffg is the best Tx in this case?
A- a careful explanation of benign nature of the complaint
B- Use of benzodiazepine
C- Skillful physician reassurance
D- Use of placebo medication
E- Psychotherapy to explore her current life circumstances

Answer is E. case of hypochondriasis which is usually becomes evident during psychological stress.


Which of the ffg risk factors are related to breast carcinoma?
A- Obesity, late manopause, first pregnancy > 35 yr, smoking, high fat diet
B- Obesity, late menopause, low fiber diet, smoking
C- First pregnancy>35 yr, obesity, smoking, family Hx, age
D- Low fiber diet, age, smoking, first pregnancy> 35 yr, late menopause
E- Age, obesity, late menopause, first pregnancy>35 yr, low fiber, high fat diet

Answer is E. Smoking is not a risk factor. The most important risk factors are:
- Age
- Family Hx
- Nulliparous state
- Early menarche
- Late menopause
- Hx of contralat. breast cancer
- First pregnancy > 35 yr
- High fat diet
- Low fiber diet


2 y/o boy who palys in a sandbox in a nursery that has couple cats for children to play with, presents with wheezing, hepatosplenomegaly & peripheral blood eosinophilia. What’s the Dx?
A- Pinworm infestations
B- Loffler’s syn.
C- Ascariasis
D- Visceral larva migrans
E- Strongyloidiasis

Answer is D. Visceral larva migrans is caused by Toxocara larva. It’s most common in children 1-4 y/o especially who have close contacts with digs & cats. Sandboxea are common places for both pets & children. Sx are: fever, hepatosplenomegaly, wheezing, pulmonaer dis. & eosinophilia



17 y/o woman G1P0 with 10 yr Hx of asthma undergoes pulmonary evaluation & spirometery. She doesn’t have any respiratory complaints or Sx. Which of the ffg regarding her status during pregnancy is true?
A- RR increases
B- Vital capacity decreases
C- Minute ventilation increases
D- Functional residual capacity remains unchanged
E- Tidal volume decreased

Answer is C. since Px does’t have any respiratory problem, she’ll undergo the normal changes in respiratory physiology that occur during pregnancy:
- RR is unchanged
- TV is increased
- Minute ventilation is increased
- VC remains unchanged
- FRC is decreased ( uterus elevates the resting position of diaphragm )


35 y/o woman with major depressive disorder, single episode has responded well to imipramine after 1 month of Tx. Which of the ffg is the most appropriate next step?
A- Continue imipramine for 6 months
B- Continue imipramine indefenitly
C- Gradual imipramine decrease till she’s medication free, unless depression occurs
D- Stop imipramine immediately
E- Switch to fluoxetine

Answer is A. Maintanace therapy after response to antidepressants should be continued for 6 months after initial response.




14 y/o girl presents with trouble concentrating at school just three months after witnessing her best friend being shot to death by another classmate. Ever since that "awful day" she has been very "sad" and withdrawn, often sitting on her bed, staring at the wall "for hours." She has frequent crying spells and refuses to play with friends or participate in her normal after-school activities. Her appetite has "dwindled down to nothing" and she feels very guilty that she survived the shooting. On further questioning, she reluctantly admits that she has constant thoughts of "joining her friend." She did not receive any counseling after the incident.
*** What’s the most likely Dx?
A. adjustment disorder
B. brief psychotic disorder
C. dysthymic disorder
D. major depressive disorder
E. normal grief
F. PTSD

*** What’s the most important q to ask at this time?
A. "Are you hearing voices?"
B. "Do you have any friends that you feel comfortable talking to at school?"
C. "Do you wear a helmet when you ride your bicycle?"
D. "Can you describe your typical weekly alcohol intake?"
E. "Have you thought of the means by which you can 'join your friend'?"


1- The correct answer is D. This patient most likely has major depressive disorder. To meet the criteria for this disorder a patient must exhibit a 2-week history of a distinct change in mood or a loss of interest or pleasure, along with at least 4 of the following: a decreased appetite and weight loss, difficulty sleeping, psychomotor retardation or agitation, fatigue, feelings of worthlessness or guilt, an inability to concentrate, and suicidal ideation. The symptoms must cause functional impairment. ( Kaplan, step 3 samples )

2- The correct answer is E. Since she has already told you that she has suicidal ideation ("joining her friend"), it is very important to ask if she has "thought of the means by which" she can "join her friend" or has made any preparatory actions.




A 64 y/o married man has been diagnosed to be HIV positive. He comes in to the office to discuss the results and begs you not to tell his wife, who is also your patient. He says that hearing what he has been in involved in "will kill her." You remind him that HIV may also "kill her." The most appropriate first step is to:

A. contact his wife anonymously and tell her that she has been exposed to HIV
B. contact the appropriate government health agency and report your findings
C. promise him that as his doctor you will respect his privacy and maintain confidentiality
D. promise him that you will keep the results confidential if he agrees to use condoms with his wife
E. try to persuade him to voluntarily discuss the issue with his wife

The correct answer is E. Physicians must violate confidentiality and warn third persons about the danger of HIV infection if the patient is unwilling to inform the person himself. Before informing third parties, the physician should try to do everything possible to persuade the patient to voluntarily discuss the issue with their partner. If the physician believes that an individual may really be saved from a deadly infection, confidentiality should be violated.



A 4 y/o boy presents with fever, irritability, and erythema of the hands and feet for the past week. His mother has been giving him aspirin to reduce his temperature. P/E on admission showed a T=39.7 C (103.4 F), bilateral conjunctival injection, an enlarged right-sided cervical lymph node (1.8-cm), fissured lips, a red tongue with red papillae, pharyngeal hyperemia, erythematous and edematous palms and soles, and a confluent, blanching erythematous rash on the trunk. IV fluids were started, the aspirin therapy was continued. Laboratory studies show ESR= 28mm/h Plt= 490,000/mm3. The patient is extremely uncomfortable and now shows desquamation of the fingers and toes. The most appropriate therapy at this time is:

A. corticosteroids
B. ibuprofen
C. intravenous gammaglobulin
D. oxacillin
E. penicillin V

The correct answer is C. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin. The disease is characterized by a high fever for longer than 5 days, bilateral conjunctival injection, fissured lips, a "strawberry tongue", mucosal change in the oral pharynx, erythematous and edematous palms and soles with desquamation, a polymorphous rash, cervical lymphadenopathy, an elevated erythrocyte sedimentation rate, and thrombocytosis. The most important complication is coronary artery aneurysms, which may be prevented by early treatment with aspirin and intravenous gammaglobulin. An echocardiogram is necessary to evaluate cardiac involvement.




47 y/o woman with a Hx of similar attacks of epigastric abdominal pain in the past was admitted to the hospital with a Dx of gallstone pancreatitis. She was NPO and IV fluid started. On the evening of admission day, the patient is noted to have T=103.4 F. Her BP & HR are within normal range. Her abdomen is diffusely tender to palpation with guarding. What’s the most appropriate management at this time?

A. draw blood cultures and await results
B. draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy
C. draw blood, urine, and sputum cultures and await results
D. obtain an urgent abdominal CT scan
E. start ampicillin, gentamicin, and metronidazole therapy

The correct answer is B. The most appropriate management at this time is to draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy. Intravenous antibiotics are only indicated if there is evidence of pancreatic necrosis or if the patient develops a fever after the diagnosis of pancreatitis is made. There is a substantial amount of clinical literature validating this approach to treating pancreatitis. The appropriate sequence of events is to draw blood cultures prior to initiating therapy in order to maximize chances of detecting an organism.




A 24 hour old male infant is noted to have some peculiar jerking movements of the right foot and arm. His axillary temperature an hour before was 36.2"C. The physical examination reveals no unusual findings except that he appears small and premature. His birth weight was 2,550 g. The mother's and infant' s history show that he was the second of twins born after 37 weeks' gestation, presented in transverse position and his heart rate had dropped to 80 per minute 10 minutes prior to birth, with documented fetal hypoxia. He had an Apgar score of 3 at 1 minute and 7 at 5 minutes. The mother had nausea and vomiting during pregnancy for which she was given vitamin B6. She had mild preeclampsia at delivery.
*** Which is the most likely diagnosis?
a) Brain tumor
b) Hypoxemia in utero and possibly during delivery
c) Cerebral trauma during delivery
d) Vitamin B6 dependency
e) None of the above
*** In the diagnostic work-up, you may obtain the following tests or procedures, EXCEPT:
a) CT scan of the head
b) Lumbar puncture for examination and culture of spinal fluid
c) Electroencephalography
d) Serology for toxoplasmosis
e) Blood levels of sugar and calcium
B & D
Hypoxemia is the leading cause of seizures considering the history of drop in fetal heart rate and low Apgar score at 1 minute. Hypoglycemia, hypocalcemia, vitamin B6 dependency, and meningitis are possible causes of seizures but unlikely and should be ruled out. Some cerebral anomaly is possible. Incidence of congenital malformations is higher in twins than , in singletons, and central nervous system malformations lead all others in frequency. Brain tumors at this age are rare and usually present with recurrent vomiting and not with seizures.



An infant who was healthy at birth is brought to your office for her first office visit at the age of 6 weeks. You notice that the infant is jaundiced and that there is bilirubin staining of the wet diaper. Which one of the following diagnoses is most consistent with these findings?
a. Physiologic jaundice of the newborn
b. Hemolysis secondary to Rh incompatibility
c. Crigler-Najjar syndrome
d. Gilbert's syndrome
e. Biliary atresia
Answer is e- biliary atresia. bilirubbin in urine a clue of direct hyperbilirubinemia



A 22 y/o man used illicit IV drugs briefly 1 year ago. He is asymptomatic and has no history of viral hepatitis. Serum ALT and bilirubin concentrations are normal. Serologic studies show:
Hepatitis B surface antigen (HBsAg) positive
Hepatitis B core antibody (HBcAb) positive
Hepatitis B e antigen (HBeAg) negative
Antibody to surface antigen (Anti-HBs) negative
Antibody to e antigen (Anti-HBe) positive

Which of the following statements best describes the current condition?
a-He is in the incubation period, is highly infectious, is likely to develop acute hepatitis B.
b-He is in the incubation period, is minimally infetious, and is likely to develop acute hepatitis B.
c-He is a chronic carrier of hepatitis B and is highly infectious.
d-He was infected previously with hepatitis B. has recovered and is immune to hepatitis B.

Answer is a.

A 35 y/o woman requests a routine health assessment. She has no specific medical complaints or past medical hstory. Her father developed colon cancer at age 54 but is still living. His brother died of colon cancer at aae 41. Their father (the patient's grandfather) died in his sixties of colon cancer. His sister died of gastric cancer. The patent's sister was recently diagnosed with endometrial cancer at age 43.
The patient has a good appetite and has no nausea, vomiting, or weight loss. She has had no change in her bowel habits or hematochezia, and her menstrual periods are normal. Physical examination is normal. Digital rectal examination is negative for fecal occult blood. A screening complete blood count and biochemical profile are normal.
Which of the following actions is most appropriate?
a. Perform annual occult blood tests of three stool specimens. Initiate screening with flexible sigmoidoscopy at age 50.
b. Perform colonoscopy at least every 2 years.
c. Barium enema now; if normal no further evaluation.
d. Perform colonoscopy now; if no polyps are seen, no further investigation is necessary.
e. Perform fecal occult blood testing and flexible sigmoidoscopy now. If no polyps are seen now, the patient should be followed routinely with fecal occult blood testing and flexible sigmoidoscopy beginning at age 50.
Answer is b.




A 20 y/o woman is evaluated for fever of nine weeks’ duration. During this time she has had daily temperature elevations to 40.0 C (104.0 F). The only other symptoms have been malaise and occasional aches in the hands and knees; on one occasion she noted a transient pink rash on the abdomen. A one-week course of ampicillin had little effect.
T=38.9 C (102.0 F); PR=108 per minute, and rhythm is regular. A grade 1/6 systolic ejection murmur is heard best at the LSB. The spleen is palpable 3 cm below the left costal margin on deep inspiration. Electrocardiogram and chest radiograph are normal. Laboratory studies:
Hct 35%
Hgb 11.5 g/dL
WBC 12,800/cu mm; 81%neutrophils,
4% monocytes, 14 lymphocytes,
1% eosinophils
ASO 250 Todd units {<200}
RF Negative
ANA Negative
Blood cultures Pending
Which of the following is the most likely diagnosis?
(A) Enteric fever
(B) Bacterial endocarditis
(C) Lyme disease
(D) Hodgkin's disease
(E) Adult-onset Still's disease
Answer is e.



A healthy 71 y/o man describes visual loss in his right eye. Flashes of light and a curtain-like loss of lateral vision began when he awoke eight hours ago. These symptoms have persisted. Which of the following is the most likely explanation?
(A) Retinal vein occlusion
(B) Retinal detachment
(C) Atheroembolic occlusion of a lateral branch of the right retinal artery
(D) Ocular migraine
(E) Occipital lobe seizure
Answer is B.



What is the marker for CREST syn. ?

A. anti-scl-70
B. anti centromere
C. anti ds-DNA
D. SS-A (Ro)

The marker for CREST is anti centromere. They both have C in it.

anti-scl-70 is for scleroderma diffuse type. They both have scl in it.

D. anti ds-DNA is for SLE.

E. SS-A is for Sjogren's disease


What’s the characteristics of rapidly progressive glomerulonephritis (RPGN)?

A. crescent formation
B. "lumpy-bumpy" subepithelial deposits
C. IgM mesangial deposition
D. Associated with Hep C

the answer is A. Rapidly progressive glomerulonephritis is characteristic of rapidly losing at least 50% of its glomeruli in as short period of time--usually days to 3 month max. Extensive fibrinoid necrosis is found on biopsy.


Pt. In mVA was brought to ER, you suspected cardiac tamponade what is next step?
a. pericardiocentesis
b. echo first..
C. CXR
d. CT

Answer: depending on senario if pt is unstable proceed to Pericardiocentesis, If stable echo first.


A patient has end stage pancreatic cancer and as her primary care pysician, she asks you how long she could survive. What you should tell her.
a. 5 year rate is 30%
b. 5 year rate is 20%
c. " 15%
d. " < 5%

Answer: D- The overall 5-year survival rate for this disease is less than 5%.


A 24-year-old white primigravida has developed several 1- to 2-mm erythematous papules on her abdomen in the third trimester. They are pruritic and tend to appear in her striae. Liver function tests and a CBC are normal.

Which one of the following is the most likely diagnosis?

a. Pruritus gravidarum
b. Spangler's papular dermatitis
c. Impetigo herpetiformis
d. Herpes gestationis
e. Pruritic urticarial papules and plaques (PUPP)

The ans is e

The findings in this patient are most consistent with PUPP. This condition is usually benign, is not associated with increased fetal morbidity, and resolves after delivery, and there is usually no recurrence in subsequent pregnancies. Herpes gestationis, impetigo herpetiformis, and Spangler's papular dermatitis have different presentations and may be associated with increased fetal morbidity. Pruritus gravidarum is characterized by pruritus without skin lesions.


Ultrasonography reveals placenta previa in a 41-year-old asymptomatic G4P3 at 21 weeks gestation. Appropriate management would be

a. weekly speculum examinations under aseptic conditions beginning in her third trimester to assess the risk of bleeding
b. an MRI scan, with a repeat scan later in the pregnancy if indicated
c. repeat ultrasonography in her third trimester
d. cesarean delivery at 28 weeks gestation if her L/S ratio is favorable
e. reassurance that ultrasound diagnosis of placenta previa without evidence of bleeding is no cause for concern and can be disregarded

The ans is c

The incidence of placenta previa ranges from 6% to 45% in the second trimester, but more than 95% of these resolve by the third trimester. However, it remains a cause for concern and should be watched, not ignored, even if there is no bleeding. This patient should have repeat ultrasonography in her third trimester. An MRI is very helpful but need not be used except in a difficult diagnostic situation. Weekly speculum examinations would create a risk of hemorrhage. Delivery at 28 weeks would not be appropriate in a patient with no symptoms and without confirmation of the persistence of placenta previa.




Which one of the following is an absolute contraindication to tocolytic treatment for preterm labor?
a. Urinary tract infection
b. Documented gestation less than 28 weeks
c. Chorioamnionitis
d. Uncontrolled diabetes mellitus
e. Any vaginal bleeding due to mild abruptio placentae

The ans is c
Before tocolytic treatment is instituted, absolute contraindications to tocolysis must be ruled out. These include chorioamnionitis, severe abruptio placentae, severe bleeding from any cause, severe pregnancy-induced hypertension, fetal death, fetal anomaly incompatible with life, and severe fetal growth retardation. Chorioamnionitis may precipitate preterm labor and is an absolute contraindication to tocolysis. It may be present in a febrile pregnant patient even with intact membranes. In this case amniocentesis may be required to rule out infection. There are also a number of relative contraindications. These include uncontrolled diabetes, hyperthyroidism, maternal cardiac disease, mild chronic hypertension, mild abruptio placentae, stable placenta previa, fetal distress, fetal anomaly, mild fetal growth retardation, and cervical dilatation greater than 5 cm. In patients with relative contraindications to tocolysis the risk of complications from prematurity must be weighed against the risk of tocolysis. Not all vaginal bleeding is due to a serious obstetric condition. Cervical effacement or dilatation may be the cause. Even if the source of bleeding is determined to be a placental abruption, if the bleeding is minor, the abruption is mild, and the fetus is not in distress, tocolysis is not absolutely contraindicated.
While diabetes mellitus may be adversely affected by beta-adrenergic tocolytic agents, it is not an absolute contraindication to tocolysis. Close glycemic monitoring is, of course, mandatory. Even a few weeks of effective tocolysis may significantly alter the perinatal outcome of gestations between 25 and 27 weeks. Gestational age less than 28 weeks is therefore not a contraindication to tocolysis. While a urinary tract infection may precipitate preterm labor, tocolysis is not contraindicated. The infection, of course, should be treated.



Which one of the following statements is most accurate concerning juvenile rheumatoid arthritis?
a. Fever is a rare systemic manifestation
b. Ten years after the onset of disease, most patients have excellent functional status
c. Most patients have a permanent deformity of at least 1 extremity
d. The disease is characterized by lifelong recurrences
e. Most patients require corticosteroid treatment

answer is b.
At least 50% of patients followed for up to 15 years have complete remission of juvenile rheumatoid arthritis, and 70% regain normal function. A few patients are left with crippling joint deformities, but 75% have no significant residual deformity. Systemic-onset disease is accompanied by high fever, rheumatoid rash, polyarthritis, and other systemic manifestations




A 5-year-old African-American male fell off his bicycle and hit the back of his head on a hard surface. There was no loss of consciousness. No other injury was noted. He was obviously agitated and restless, and his only complaint was a loss of vision. When you see him, his examination is unremarkable except for moderate swelling over the occipitoparietal area of the scalp. His skin is intact, and no gross neurologic deficit is noted except for the visual loss. A CT scan is negative. An EEG shows only slight slowing of activity.
Which one of the following statements is true regarding this patient?

a. The child's vision will probably return within 24 hours
b. The child should be hospitalized for 72 hours for further observation
c. It will be months before the child's vision returns
d. The loss of vision is probably caused by damage to the optic nerve

Ans is a
Transient cortical blindness following mild head trauma is usually associated with a benign outcome. The special features are mild head trauma, no loss of consciousness, onset of blindness occurring within hours of the trauma, duration of blindness less than 24 hours, absence of skull fracture or visible injury on CT scan, and no other neurologic deficits. The EEG shows initial slowing with normalization on follow-up.



which of the following medication is known to exacerbate psoriaisis?
a)prednisone
B NSAID
c hydroxychloroquine
d methotrexate

answer is c.



1- A 20 y/o man who moved to the US from Cambodia 2 years ago presents to the ER with the sudden onset of left hemiparesis. His wife, who emigrated with him, reports that he has not felt well for at least a month and has had a weight loss of about 9 kg (20 lb). On P/E, T=38 °C (100.4 °F) and BP=116/52 mm Hg. He is somewhat cachectic and hemiparetic. The cardiac examination shows a murmur. The physical examination is otherwise normal.Which of the following tests is most likely to give the diagnosis?
(A) Blood cultures
(B) Lumbar puncture
(C) Radiography of the chest
(D) Complete blood count, differential, platelet count, and erythrocyte sedimentation rate
(E) Biopsy of inguinal lymph node
(F) head CT scan
Answer is A.The appearance of focal neurologic signs in a young person from Cambodia raises a wide differential diagnosis. Atherosclerotic cerebrovascular disease is uncommon in the 20-year-old age group. Among other diagnostic considerations are an embolic event from a cardiac source, such as a valvular vegetation associated with endocarditis or an atrial myxoma; vasculitis; tuberculomatous or bacterial brain abscess; brain tumor; aneurysm or arteriovenous malformation; and coagulation disorder such as thrombotic thrombocytopenic purpura or hyperviscosity syndrome caused by multiple myeloma.
Neurologic complications occur in 25% to 40% of patients with infective endocarditis. About 15% develop cerebral emboli with associated neurologic symptoms. The easily associated triad of new focal neurologic deficits, fever, and changing heart murmur occurs in only 33% of patients, so infective endocarditis must be considered in any patient with sudden focal neurologic deficits who has no conventional risk factors, such as atherosclerosis.


2- A 35 y/o woman presents with a 1.5-cm Lt breast mass which is nodular with indistinct borders. Her mother and maternal aunt both had breast cancer in their forties.
How would you evaluate this woman's condition?
(A) Observe through a menstrual cycle
(B) Diagnostic mammogram
(C) Breast ultrasound
(D) Office needle aspiration
This woman has a significant risk for breast cancer. The suspicion of cancer is high because of the characteristics of the mass and the family history of early-age breast cancer. The first approach would be a diagnostic mammogram to further define the lesion and, equally important, to look for suspicious lesions in the opposite breast. Even if the mammogram is negative, referral to a surgeon for biopsy would be the next step.


3- A 22-year-old female primagravida is seen in prenatal clinic 5 months after her last menstrual period. Her pregnancy has been uneventful, and she has gained weight progressively over the last 2 months. Three months ago, her blood pressure was 120/80 mm Hg, and there was 2+ protein on dipstick urinalysis. Today she has a blood pressure of 150/95 mm Hg and marked bilateral lower extremity edema.
Laboratory studies:
Hematocrit 29.7%
Leukocyte count 4200/L
Platelet count 209,000/L
Blood urea nitrogen 15 mg/dL
Serum creatinine 1.1 mg/dL
Serum uric acid 6.0 mg/dL
Urinalysis:
Protein 4+
Microscopic Hematuria, rare erythrocyte casts, rare broad casts, few leukocytes
24-hour urine protein excretion 12.5 g
Creatinine clearance 80 mL/min
This clinical presentation is most consistent with:
(A) Preeclampsia
(B) Underlying renal disease present before conception
(C) Hypertensive nephrosclerosis
(D) Pyelonephritis
Answer is B. In this 22-year-old pregnant woman, it is critical to determine whether previously existing underlying renal disease is present because of the overlap with signs of preeclampsia and the differing prognoses of the two conditions. Preeclampsia is a complication that presents after 20 weeks of gestation, which suggests the abnormal proteinuria in this patient is associated with another disease. The finding of 2+ protein on dipstick urinalysis is not specific, but the hematuria and erythrocyte casts suggest underlying glomerulonephritis rather than preeclampsia.


4- A 50-year-old man who has had diabetes mellitus for 12 years is concerned about becoming dependent on dialysis. His disease has been inadequately controlled (hemoglobin A1C range 8.7% to 11.8%). His urinalysis is strongly positive for protein, and his serum creatinine concentration has increased from 1.2 to 1.9 mg/dL in the past 8 months. His blood pressure has been 150/90 mm Hg and on occasion as high as 210/120 mm Hg. Which treatment is most important to reduce the process of this patient's kidney disease?
A. Insulin
B. Antihypertensive agent
C. HMG-CoA reductase inhibitor ("statin")
D. Protein-restricted diet
E. Aspirin
Answer is B. This patient has already started on the path to progressive diabetic nephropathy. Although all of the preventive measures still warrant attention, blood pressure control at this stage is most important. From the onset, good glycemic control (hemoglobin A1C 7% to 7.5%), a protein-regulated diet to reduce intraglomerular pressure as well as antihypertensive therapy with an ACE-inhibitor should be considered.Antihypertensive therapy attenuates the decline in renal function in patients with all forms of diabetes.

5- A 26-year-old patient is presented with amenorrhea of 2.5-month duration. Lab analysis indicates increased levels of thyroid and cortisol binding proteins. There is an elevated total cortisol and ACTH. Free cortisol level is within normal range. These findings are most likely suggestive of which of the following conditions?

A. Hypothyroidism
B. Addison's disease
C. Conn's disease
D. Cushing's disease
E. Pregnancy
answer is E.

Two weeks following a viral illness, a teenage boy breaks out in an evolving rash that is remarkable for target lesions. What is the primary treatment?
a. Epinephrine
b. Glucagon
c. Corticosteroids
d. Antihistamines
e. Symptomatic or supportive therapy depending on severity.
Answer is e. it’s erythema multiform

The most prevalent of allergic disease in school-age children is:
a. Atopic dermatitis
b. Food allergy
c. Asthma
d. Allergic rhinitis
e. Drug allergy
Answer is d.

Cheilosis and glossitis are features of ( more than one answer ):
a. vit A def.
b. riboflavin def.
c. vit. C def.
d. pyridoxine def.
e. vit. E def.
Answers are b&d.
Which one is the most common adverse effect of intranasal steroids?
a. Nasal irritation
b. Septal perforation
c. Nasal bleeding
d. Short stature
e. Adrenal suppression
Answer is a.

Increased risk for intussusception was observed as a rare complication following immunization with which vaccine?
a. IPV
b. OPV
c. Rotavirus vaccine
d. HAV
e. HBV
Answer is c.


A 60 y/o Japanese man visiting US with excellent health until 6 months ago, when he first noted mild upper abdominal fullness after meals. On P/E hyperpigmented, heaped-up velvety lesions in the neck, axillae, and groin is noted. Which of the following conditions is associated with the skin findings?

a- Non-Hodgkin's lymphoma

b- Anorexia nervosa

c- Acute leukemia

d- Adenocarcinoma of the stomach

e- Addison's disease

Answer is d, skin lesion is acanthosis nigricans.

Which of the following should be done annually after age 40 in the asymptomatic, average- risk man in order to promote the early detection of cancer?

a- Colonoscopy

b- Sigmoidoscopy

c- Digital rectal examination with palpation of the prostate

d- Digital rectal examination with palpation of the prostate and stool guaiac

e- Digital rectal examination with palpation of the prostate, stool blood test, and chest x-ray

Answer is c.

During a routine checkup, a 65 y/o man is found to have a level of serum Alk Ph. three times the upper limit of normal. Serum Ca and ph. concentrations and LFT results are normal. He is asymptomatic. The most likely diagnosis is

a- metastatic bone disease

b- primary hyperparathyroidism

c- occult plasmacytoma

d- Paget's disease of bone

e- osteomalacia

answer is d.


Which of the following is NOT a predisposing factor for the development of a hernia?
a- Ascites
b- Obesity
c- Cystic fibrosis
d- Chronic obstructive pulmonary disease
e- Peritoneal dialysis

answer is b. Ascites, peritoneal dialysis, ventriculoperitoneal
shunt, cystic fibrosis, and chronic obstructive pulmonary disease all predispose patients
to hernia formation because they increase intraabdominal pressure. Other risk factors
include a positive family history, undescended testis, and genitourinary abnormalities.



A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The pregnancy and delivery were normal; the infant received phototherapy for 1 day for
hyperbilirubinemia. He had an episode of otitis media 1 month ago. There is no chronic runny nose or strong family history of asthma. He spits up small amounts of formula several times a day, but otherwise appears well. His growth curve is normal. An examination is unremarkable except for mild wheezing. Which one of the following is the most likely diagnosis?
A) Benign reactive airway disease of infancy
B) Cystic fibrosis
C) Unresolved respiratory syncytial virus infection
D) Early asthma
E) Gastroesophageal reflux

Answer is E, gastroesophageal reflux is a common cause of wheezing in infants. At 5 months of age, most infants no longer spit up several times a day, and this is a major clue that the wheezing may be from the reflux. Also, there is no family history of asthma and the wheezing is not related to infections. Cystic fibrosis is more likely to present with recurrent infections and failure to thrive than with intermittent wheezing.




*** ECG findings of pulmonary edema include all of the following except:
a- deep S1
b- depressed ST in lead I & II
c- prominent Q1 & inversion of T3
d- left axis deviation
e- clockwise rotation in the precordial leads

answer is d. it cause Rt. axis deviation.



*** chest pain & friction rub 3 days after admission to ICU, indicate which of the ffg?
a- misdiagnosis of infarction
b- chest trauma
c- viral infection
d- transmural infarction
e- dissecting aneurysm

answer is d.


*** Neuropathy secondary to gout manifests as:
a- NS
b- ARF
c- ATN
d- Isosthenuria & moderate albuminuria
e- Malignant HTN

Answer is d.


*** Tx of choice for cutaneous manifestation of protoporphyria is:
a- phenobarb.
b- Corticosteroid
c- High carb. Diet
d- Beta caroten
e- Chlorpromazine

Answer is d.


*** 25 y/o female with intermittent double vision, on CXR an Ant. Mediastinal mass is noted. What’s the next step of Mx?
a- serum Ca messurement
b- brain MRI
c- evaluation of T cell function
d- serum gamma globulins messurement
e- order GTT

answer is d. association of thymoma and myasthenia gravis. 5-10% of Px with thymoma have low serum gamma globulins.


*** 76 y/o male with 80 pack/y smoking Hx, was diagnosed with lung cancer 4 m ago, he’s brought to hospital in state of coma, his serum ca= 16 mg/dl, which of the ffg, would be the most useful to reduce ca rapidly:
a- acetazolamide
b- furesmide
c- hydrochlorothiazide
d- manitol
e- spironolactone

answer is b- furesmide which increase urinary excretion of ca.



*** 50 y/o man with Hx of smoking & cough for the past 2 months, is found to have a solitary pulmonary nodule with no mediastinal dis on CXR. He’s expected to have best prognosis if he has which type of ffg tumors?
a- small cell carcinoma
b- poorly diff. Adenocarcinoma
c- metastatic carcinoma
d- well diff. SCC
e- well diff. Adenocarcinoma

answer is e- well diff adenocarcinoma



*** 27 y/o woman presents with sudden pain & decrease in hearing in Rt. ear while picking it with matchstick. On P/E, a traumatic rypture of Rt. tympanic membrane & some blood clot is seen. What’s the best advice or procedure?
a- advice her to use earplug while shampooing & showering
b- advice her to clean the ear canal with Q-tips
c- remove the blood clot
d- antibiotic eardrops
e- oral + eardrop antibiotics

answer is a- advice her to use earplug while shampooing & showering



*** 3 days after hospital admission wih Dx od acute pancreatitis, a 45 y/o man has 5 of the ranson criteria, On P/E, T=102, BP=120/70, PR= 130, RR= 18, Px is in obvious distress, abdomen is distended with no audible bowel sounds, tenderness on upper abd. without any rebound tenderness is noted. What’s the best next step to confirm the Dx?
a- serum amylase
b- paracentesis
c- ERCP
d- Dynamic CT scan
e- Laparascopy
f- US
g- Abdominal x-ray

Answer is d- dynamic CT scan is the best investigative way for pancreatic necrosis.



*** A 65 y.o. man with ischemic heart disease comes to the ER in acute CHF. The ophthalmic medicine most likely to be responsible is
a. Acetazolamide
b. Pilocarpine
c. Tobridex
d. Trifluoridine
e. Timolol maleate

Answer is e- timolol maleate.



*** A 40 y.o. w/spastic bladder is treated w/ anticholinergics. The pt. will complain of:
a- Diplopia
b- Decreased distance vision
c- Decreased near vision
d- Decrease in color vision
e- Snowy, sparkly vision

Answer is c- decreased near vision


*** Which of the following lab values would be most consistent with a woman who has a Hx of lung cancer and has been on chemotherapy for several weeks.The patient now presents with acute anemia.
a. reticulocyte count of 60 x 109
b. plasma Hgb of 7.2 g/dl
c. Hct of 34%
d. MCV of 70 fL
e. RBC of 5.9 million/mm3

answer is a.


*** A healthy 12-month-old boy has a brother with adenosine deaminase deficiency. Which of the following vaccines should you NOT administer to the infant?
(A) Diphtheria-tetanus-pertussis (DTP)
(B) H. influenzae (HiB)
(C) Hepatitis B (Hep B)
(D) Oral polio vaccine
(E) Measles-mumps-rubella (MMR)
answer is D- The main problem in this scenario is administering a live, attenuated vaccine that may be followed by transmission to the immunocompromised sibling and cause severe, possibly fatal, disease. Of the attenuated vaccines, the oral polio vaccine is the most dangerous because the virus is shed in the feces, while attenuated vaccines administered by inoculation (such as measles-mumps-rubella), which are not shed by the recipient, are considerably less likely to be transmitted from person to person. The other three vaccines are not live vaccines and have no special risk in an immunocompromised individual


*** A 30-year-old man sustains brain damage as the result of an automobile accident. Neurologic examination reveals incomplete retrograde amnesia and severe anterograde amnesia as well as inappropriate social behavior, including hyperphagia, hypersexuality and general disinhibition. The brain injury would most likely involve the:
(A) frontal lobes, lateral convexity.
(B) frontal lobes, medial surface.
(C) temporal lobes, lateral convexity.
(D) temporal lobes, medial surface.
(E) thalami.
Answer is D- Bilateral damage of the medial temporal gyri, including the amygdalae, may cause severe memory loss (hippocampal formations). Such damage to the amygdalae may lead to inappropriate social behavior (e.g., hyperphagia, hypersexuality, general disinhibition). Bilateral destruction of the amygdalae results in the Klüver-Busy syndrome.


*** A 24 y/o college student, G1P1 presents for her annual pelvic examination and Pap smear, and renewal of her ocp. Hx & P/E are unremarkable. Her Pap smear is subsequently reported as high-grade squamous intraepithelial lesions (HGSIL). The most appropriate next step in this patient's management is
(A) Repeat Pap smear in one year.
(B) Repeat Pap smear now.
(C) Colposcopy with ECC and directed biopsy.
(D) Excisional biopsy.
(E) Cervical conization.

Answer is C. HGSIL on screening examination requires histologic diagnosis so that appropriate treatment can be selected. Repeat Pap smear is another screening test and is thus inappropriate. Conization for diagnostic purposes is needed only if colposcopy and biopsy prove inadequate.



*** A 63 y/o man with no significant past medical history is admitted with an acute abdomen secondary to gastric perforation. If a definitive ulcer procedure is performed on this patient, which of the following procedures is associated with the lowest ulcer recurrence rate?
(A) Truncal vagotomy
(B) Truncal vagotomy and pyloroplasty
(C) Vagotomy and antrectomy
(D) Parietal cell vagotomy
(E) Gastric bypass
answer is c. Among the choices provided, vagotomy with a simultaneous antrectomy has the lowest ulcer recurrence rate. However, this procedure is associated with a higher morbidity secondary to anastomotic complications (e.g., leak or stricture) or problems associated with denervation of the proximal stomach and distal bowel. Complications include postvagotomy diarrhea, dumping syndrome, delayed gastric emptying and alkaline reflux gastritis.



*** A 16 y/o boy presents to his physician with a history suggestive of systemic lupus erythematosus. The patient has a rash, arthralgia and mild proteinuria. Serologic evaluation detects no antibodies of diagnostic value. Which one of the following diseases is most likely to be diagnosed in this patient?
(A) Rheumatoid arthritis
(B) Common variable hypogam-maglobulinemia
(C) C2 deficiency
(D) Sjögren's syndrome
(E) Wegener's granulomatosis

answer is c. A deficiency in complement component C2 may manifest itself as a disorder similar to systemic lupus erythematosus, possibly because of a failure of complement-dependent mechanisms to eliminate immune complexes. Most patients with rheumatoid arthritis have several antibodies (most notably the anti-IgG antibody known as rheumatoid factor). Similarly, Sjögren's patients are diagnosed by detection of antibodies to exocrine gland duct epithelium. Patients with Wegener's granulomatosis have antineutrophil cytoplasmic autoantibodies. Common variable hypogammaglobulinemia will evidence itself by the occurrence of repeated bacterial infections.



1- a 4 y/o child presents with upper respiratory illness. P/E reveals mental retardation, eczema, hypopigmentation and blue eyes. What’s the most likely Dx?
a- Down syn.
b- Tuberous sclerosis
c- PKU
d- Osteogenesis imperfecta
e- Cretinism
f- Galactosemia

Answer is PKU.



2- 28 y/o male IV drug abuser presents with painful, erythematous nodules on fingerpad and linear hemoorhage beneath the fingernail of indexfinger. On P/E a grade II, high pitched diastolic murmur is heard on 2nd & 3rd Rt. ICS. What’s these lesion on the hand are related to?
a- immunocmplex vasculitis
b- thrombocytopenia
c- coagulation factor def.
d- DIC

Answer is a. Px has infective endocarditis due to staph, aureus involving aortic valve.the nodules are osler’s nodes and nailbed finding is splinter hemorrhage and both are example of immunocomplex vasculitis.


3- 53 y/o woman presents with SOB and weight loss despite eating well, she also have intermittent episodes of heart racing. On P/E, multinodular thyroid and warm and moist palm are noted. Hr=106/min, what’s the most likely Dx?
a- grave’s dis.
b- Papillary adenocarcinoma
c- Plummer’s dis.
d- Follicular adenoma

Answer is c ( or toxic nodular goiter ), it’s hyperthyroidism associated with multinodular goiter.


4- on a routine examination of a 5 y/o female a heart murmur is heard. It’s medium pitched, systolic ejection murmur, with musical quality. Which of the ffg is the characteristic of this murmur:
a- it’s best heard along the lower Lt. & midsternal border
b- it’s common in infancy
c- it’s best heard while Px is lying down on the Lt.
d- it’s less intense with fever or excitement

answer is A. an innocent murmur, which is best heard in supine position. It occurs only in systole ( never in diastole ), uaually grade I or II, and heard on LSB in children between ages 3-7 ( rarely in infancy ).


5- Which of the ffg is consistent with an adult Px with RA & salysilate intoxication:
PH PCO2 Bicarb
a- 7.29 53 25
b- 7.38 22 12
c- 7.53 49 39
d- 7.43 70 46
e- 7.28 28 12

answer is b. respiratory alkalosis+metabolic acidosis



** 32 y/o athelete presented with jaundice.no previous liver disease.investigation showed elevated Alk Ph.,no viral infection and no stones. what is ur presumptive diagnsis and possible cause?
cholestatic jaundice due to methyl testosterone administration.


** 35 y/o woman had an attack of billiary colic. which analgesic is contraindicated and why?
morphine increase intrabilliary pressure which worsens the pain.





1- A 70-year-old African-American male who has been hospitalized for 2½ weeks for congestive heart failure develops severe, persistent diarrhea. For the past 3 days he has had abdominal cramps and profuse semi-formed stools without mucus or blood. The patient’s current medications include captopril (Capoten), digoxin, furosemide (Lasix),
subcutaneous heparin, spironolactone (Aldactone), and loperamide (Imodium). He has coronary artery disease, but has been relatively pain free since undergoing coronary artery bypass surgery 4 years ago. An appendectomy and cholecystectomy were performed in the past, and the patient has since been free of gastrointestinal disease. On physical examination his blood pressure is 100/80 mm Hg, pulse 100 beats/min and regular, and temperature 37.0° C (98.6° F). He has mild jugular venous distention and crackles at both lung bases. Examination of his heart is unremarkable, although there is 1+ dependent edema. His abdomen is diffusely tender without masses or organomegaly. Rectal examination is normal. The results of routine laboratory tests, including a CBC, chemistry profile, EKG, and urinalysis, are all normal. The stool examination shows numerous white blood cells. Of the following, the most likely diagnosis is
A) viral gastroenteritis
B) Clostridium difficile colitis
C) ulcerative colitis
D) gluten-sensitive enteropathy (celiac sprue)
E) digoxin toxicity

This patient most likely has Clostridium difficile colitis, suggested by semiformed rather than watery stool, fecal leukocytes (not seen in viral gastroenteritis or sprue), and a hospital stay greater than 2 weeks. While this disease has traditionally been associated with antibiotic use, it is posing an increasing threat to patients in hospitals and chronic-care facilities who have not been given antibiotics. The primary sources for infection
in such cases have been toilets, bedpans, floors, and the hands of hospital personnel. Prompt recognition and treatment is essential to prevent patient relapse and to minimize intramural epidemics. The diarrhea of ulcerative colitis usually contains blood and occurs intermittently over a protracted course. Digoxin toxicity is likely to be accompanied by electrocardiographic and laboratory abnormalities, particularly hyper- or hypokalemia.




2- A 79-year-old man is admitted to the medical ward 3 days status post subdural hematoma drainage, C3 cervical spine fracture, and fixation of multiple extremity fractures sustained in a motor vehicle accident. The patient is now awake and oriented to person, place, and time, but is a lower cervical spine incomplete quadriplegic. Physical examination reveals some minimal sensation in the legs, but no ability to move the extremities. There is a Foley catheter in place that is draining yellow colored urine. Doppler ultrasonography demonstrates a thrombus in the left popliteal vein. The most important next step in the management of this patient is
A. daily Doppler ultrasonography of the lower extremities
B. inferior vena cava filter placement
C. subcutaneous heparin
D. tissue plasminogen activator thrombolysis
E. warfarin
F. weekly ventilation/perfusion scans for a pulmonary embolus

The correct answer is B. This patient has documented deep venous thrombosis (DVT) on ultrasonography and has had recent intracranial surgery. Intracranial surgery is an absolute contraindication to anticoagulation. Because the patient has a documented DVT, an inferior vena cava filter is necessary to prevent potentially fatal pulmonary emboli.

Daily ultrasonography of the lower extremities (choice A) is a way to follow the extent of the documented thrombus in the left popliteal vein. It is not sufficient to simply follow the extent of the clot, however. The known DVT puts him at a risk for a pulmonary embolus, and therefore he needs an inferior vena cava filter.

Anticoagulation with subcutaneous heparin (choice C) is absolutely contraindicated as the patient has had recent neurosurgery.

Thrombolysis (choice D) will treat the current thrombus in the left popliteal vein, but it will not prevent further thromboses from occurring. Thrombolysis with tissue plasminogen activator is also contraindicated so soon after intracranial surgery.

Anticoagulation with warfarin (choice E) is absolutely contraindicated as the patient has had recent neurosurgery.

A screening study for pulmonary emboli (choice F) is inadequate for this high-risk patient. Although both ventilation/perfusion scanning and CT pulmonary angiography are effective studies to diagnosis a pulmonary embolus, this patient needs definitive treatment to prevent a pulmonary embolus.




3- A 23-year-old college student comes to the clinic because of odynophagia with solids and liquids and dysphagia that is most severe when eating solid foods. The patient had a past medical history of Shigella colitis last year while she was a Peace Corps volunteer in Peru. She takes oral contraceptives and smokes 1 pack of cigarettes daily. She does not drink alcohol. Vital signs are: temperature 37.8 C (100 F), blood pressure 100/70 mm Hg, pulse 79/min, and respirations 8/min. Physical examination is normal. Electrocardiogram reveals normal sinus rhythms with a rate of 85/min and a markedly enlarged QRS complex in leads V3-V5. Chest x-ray reveals an enlarged cardiac silhouette. A barium esophagram demonstrates a tapering of the distal esophagus that eventually releases as the esophagus is distended. There is no evidence for extrinsic or intrinsic compression of the distal esophagus or an esophageal mass. There is no reflux. The test most likely to lead to a unifying diagnosis in this case is
A. an agglutination test for trypanosomes
B. a chest CT
C. an esophageal manometry
D. a liver biopsy
E. a myocardial biopsy
The correct answer is A. The findings of achalasia and cardiomyopathy in a patient with history of travel to Central or South America support the diagnosis of Chagas disease. This is caused by infection of Trypanosoma cruzi in the muscles of the heart, esophagus, and colon. A serum agglutination test is a noninvasive means of testing for this infection, and is highly sensitive. Left untreated, heart failure and megacolon could develop.

A chest CT (choice B) would not reveal any specific findings of Chagas disease. Using a CT to evaluate for an occult cancer causing esophageal narrowing is superfluous given the findings on the barium esophagram, which is specific for achalasia.

An esophageal manometry (choice C) is a confirmatory test for achalasia. Given the highly suggestive findings of achalasia on the barium esophagram, manometry would not be necessary.

A liver biopsy (choice D) has no role in the evaluation of Chagas disease.

A myocardial biopsy (choice E) is not necessary to diagnose Chagas disease with the availability of the serum agglutination test for trypanosomes. Invasive procedures should be deferred until they are absolutely necessary.





4- A 17-year-old girl is brought to the office by her mother because she has missed “many periods”. The girl admits to binge eating and exercising in order to prevent weight gain. She tells you that she is definitely not pregnant, because she has not had any sexual relations in the past 11 months and thinks she is not getting her menstrual period because of the excessive physical exercise she has been doing in the past several weeks. Physical examination is significant for bradycardia and significant weight loss compared to the last year. A pregnancy test is negative.At this time you should order
A. amylase
B. BUN and creatinine
C. liver function tests
D. serum potassium
E. thyroid function tests
The correct answer is D. Bulimic patients frequently engage in compensatory behaviors to prevent weight gain. Those include self-induced vomiting, abuse of diuretics, laxatives, enemas, or diet pills. The metabolic disorders frequently seen in these patients are, mostly hypokalemia and hypomagnesemia.

Amylase (choice A) is not a routine test ordered in bulimic patients. If there has been evidence of long starvation and suspicion of other medical conditions, its level might alter.

BUN and creatinine (choice B) can be increased if there are signs of dehydration, secondary to the abuse of diuretics. Otherwise, these values should not be changed significantly.

Liver function tests (choice C) are usually not changed in bulimic patients. They can be ordered to rule out other medical conditions if necessary.

Thyroid function tests (choice E) should be done as a part of regular workup of patients presenting with this clinical picture. It is not, however, the first to be ordered.





5- A 76-year-old woman is brought to the hospital by her son because of "rapid breathing." She has advanced Alzheimer disease and is unable to give a coherent history. She was recently diagnosed with breast cancer. She lives alone, but normally has a health care aide during the day. The aide was not available when the son tried to reach her to ask if anything happened. The son has not seen his mother in 2 months. An accentuated fall in systolic blood pressure during inspiration would most likely suggest
A. anxiety
B. cardiac tamponade
C. myocardial infarction
D. senile aortic stenosis
E. sepsis
The correct answer is B. This question describes pulsus paradoxus, which is when there is an accentuated fall in systolic blood pressure (>10 mm Hg) during inspiration. There is usually a small decrease in blood pressure during inspiration, but it is exaggerated in cardiac tamponade because the external compression caused by fluid accumulation around the heart leads to impaired ventricular filling, reduced left ventricular stroke volume, and a reduction in systolic blood pressure. Cardiac tamponade can occur acutely after trauma or develop chronically from the accumulation of pericardial fluid malignancies (she has breast cancer), uremia, infections, collagen vascular diseases, or radiation.

All of the other choices, anxiety (choice A), myocardial infarction (choice C), senile aortic stenosis (choice D), and sepsis (choice E), may be associated with tachypnea, but are not usually direct causes of pulsus paradoxus.



*** A 5 y/o boy is brought to the clinic because of a fever for 5 days and a sore throat and malaise. The mother tells you that he is usually a very healthy child and he is up to date on all of his immunizations. Besides the mother, he lives at home with an older brother and sister, neither of them are sick. On P/E, T=39.5 C (103.1 F), he has a peeling rash on his extremities, one 2 cm lymph node on the right anterior cervical chain, a confluent truncal rash, and mild conjunctivitis. Appropriate management is taken. The most important long-term Mx of this child is:
A. antibiotic prophylaxis to prevent rheumatic fever
B. echocardiograms to look for coronary artery aneurysms
C. excisional biopsy and surveillance of lymph nodes for malignancy
D. nothing, as this is a case of scarlet fever and he will completely recover
E. serial lumbar punctures
The correct answer is B. The vignette demonstrates a case of Kawasaki disease which is characterized by high fever for >5 days, unilateral cervical lymph node, macular papular rash to truck, peeling of hands and feet, and conjunctivitis. The most important sequela of Kawasaki is the development of coronary aneurysms, and so children need to be monitored with EKGs and echocardiograms for at least 2-3 months after the acute illness. Aneurysms form from 7-45 days after illness onset.

Streptococcal pharyngitis is characterized by erythema of the oropharynx, palatal petechiae, and cervical lymphadenopathy. There is no peeling, rash or conjunctivitis. Antibiotics are used for treatment and rheumatic fever prophylaxis (choice A).

The enlarged lymph node is a reactive lymphadenopathy and need not be biopsied or excised (choice C). Upon proper treatment for KD, lymphadenopathy regresses.

This is not a case of scarlet fever (choice D) which is characterized by exanthem and a fine, sandpapery rash, and is usually caused by Streptococcus.

Although children with KD often present with a toxic appearance, lumbar punctures (choice E) is not the standard of care and need not be performed.



*** A 57-year-old woman with a long history of Crohn's disease comes to the office because of slowly progressive ataxia and paresthesias. She is currently off all medications. Physical examination shows a decreased vibratory and positional sense and mild ataxia. A CT of the head is unremarkable. Laboratory studies show:

You suspect B12 deficiency secondary to Crohn's disease. A Schilling test is performed. You expect the study to show:
In order: Radiolabeled Vitamin B12 urinary excretion, Radiolabeled B12 excretion after intrinsic factor added , Radiolabeled B12 excretion after intrinsic factor + antibiotics
A. Normal / Normal / Normal
B. Low/ Normal/ Normal
C. Low /Low/ Low
D. Low /Low/ Normal
E. Normal /Low/ Normal
The correct answer is C. This patient likely has a lesion in her ileum from Crohn's disease. This is the area where B12 is preferentially absorbed. If there is a lesion in the ileum, the Schilling test will reveal no ability to absorb B12. An understanding of the Schilling test should facilitate answering this question. If B12 deficiency develops, a Schilling test can help to define why this happened. The first step is to saturate the body with B12 by giving a large IV dose of normal B12. Simply, this ensures that any additional B12 absorbed will be excreted in the urine. This patient does not lack intrinsic factor so adding IF will not improve B12 absorption. Additionally, this patient's problem is not the lack of dietary B12, so giving B12 alone could not correct the underlying problem.



*** You are asked to see a 3 wk/o infant in the ED with a 1-day history of fever. The parents measured his temperature because he "felt warm" to them and found a temperature of 38.3 C (101.0 F). He has been feeding normally, taking 2 ounces of formula every 3-4 hours. He had 6 wet diapers the previous day. Examination shows an active infant with a temperature of 38.8 C (101.8 F). His skin perfusion is good and his physical examination, including examination of his tympanic membranes, is normal. There are no ill household contacts. The most appropriate next step is to
A. discharge the patient with close outpatient follow up
B. inquire about the mother's group B streptococcal status at delivery
C. obtain the infant's vaccination history
D. order a urinalysis and, if negative, do blood and CSF cultures
E. send blood, urine, and CSF cultures and begin empiric intravenous antibiotic therapy
The correct answer is E. There is absolutely no way to reliably distinguish a self-limited viral illness from sepsis or meningitis in an infant less than 4-weeks of age. Accordingly, all infants with a fever greater than 38 C (100.4 F) in this age group require full evaluation, including admission and parenteral antibiotics. The incidence of sepsis is somewhere between 5-10% with this degree of fever and can be catastrophic if missed, resulting in death or permanent neurologic disability.

Discharging the patient (choice A) is inappropriate because well-appearing infants in this age group may still have a potentially lethal bacterial disease.

At 3 weeks, this infant is at the peak incidence of late onset group B streptococcal disease, but the mother's group B streptococcal status (choice B) does not correlate well with occurrence of late onset group B streptococcal disease and so it is not relevant here. Maternal group B streptococcal screening is useful in the management of early-onset disease (disease within the first few days of life).

At 3 weeks this infant is unlikely to have received any vaccinations (choice C), with the possible exception of hepatitis B vaccine. He would not in any case have received Haemophilus influenzae or conjugated Streptococcus pneumoniae vaccine, which are the only two that could potentially influence his susceptibility to sepsis or meningitis.

Urinalysis (choice D) is not reliable in excluding urinary tract infection in very young infants, and therefore is not a good screening test to decide if further evaluation is necessary.



*** A 30 y/o woman is brought to the emergency department after a high-speed MVA in which she was an unrestrained driver. She was conscious at the scene with a Glasgow Score of 13. There were beer bottles evident in the car. On arrival at the emergency department, primary survey shows an abdominal bruise on the RUQ. Her vital signs are stable and blood alcohol level is 2449 mg/dL. Her PMH is remarkable for alcoholic pancreatitis twice in the previous 3 years. The patient complains of marked right upper quadrant pain and has significant tenderness on palpation of her right upper and right lower quadrants. An abdominal CT scan shows pericholecystic fluid and possible gallbladder wall thickening. The most appropriate next step to diagnose possible gallbladder rupture is:
A. diagnosis can be made by CT scan alone
B. ERCP
C. HIDA scan
D. exploratory laparoscopy
E. exploratory laparotomy
The correct answer is D. This patient has suffered a traumatic injury to her right upper quadrant and there is a clinical suspicion of gallbladder rupture. The gold standard for such a diagnosis is direct visualization. Since laparoscopy is widely available, it has become the modality of choice to undertake direct visualization of the suspected injury.

The diagnosis cannot be made by CT alone (choice A). The CT shows only pericholecystic fluid. This is consistent with chronic or acute cholecystitis, both of which are a possibility given her history of alcohol use and pancreatitis. The issue, given her trauma, is whether the gallbladder has ruptured.

An ERCP (choice B) is an endoscopic diagnostic and therapeutic tool for the management of biliary disease. It has no role in the diagnosis of gallbladder rupture. It can however be used to demonstrate gallbladder filling with contrast after the removal of biliary stones.

A HIDA scan (choice C) is an imaging modality utilizing radioactive tracers to visualize the gallbladder. However, given the widespread use of laparoscopic equipment, this test has been largely supplanted by the new, more sensitive diagnostic laparoscopy.


Exploratory laparotomy (choice E) has attendant intra- and postoperative complications that make it largely reserved for centers where laparoscopy is not available. It is also reserved for patients with extensive abdominal trauma or clinical signs and symptoms consistent with massive abdominal pathology where laparoscopy would not be useful or for patients that require a laparotomy for another indication.




*** A 64 y/o man comes to the clinic because of a "spot" on the side of his face that has been there for about 8 months. He says that he is an executive at a local company and is retiring at the end of the year. The company has hired a portrait artist to paint his picture that will hang in the boardroom for many years to come, and so he realized that this is a good time to "have this thing taken off." He thinks that the lesion has not grown since he noticed it, but he has not paid it much attention. He plays tennis every weekend at his country club and then lies in the sun with his wife. This is the first time you have seen this patient, but he tells you that he has been very healthy and has only suffered through "a couple of bouts of kidney stones" over the years. Physical examination shows a 2.3-cm waxy, verrucous, dark brown papule with a “stuck-on” appearance.The most likely diagnosis is
A. actinic keratosis
B. basal cell carcinoma
C. dermatofibroma
D. melanoma
E. psoriasis
F. seborrheic keratosis
G. squamous cell carcinoma
The correct answer is F. This patient most likely has seborrheic keratosis. This lesion is characterized by light brown to black papules or plaques with an adherent waxy, greasy scale. The "stuck-on" appearance is very characteristic. It is most often found on the face and trunk.



A 35 y/o white female is brought to your office after a brief loss of consciousness. No tonic-clonic activity was observed, nor did the patient experience urinary incontinence. She recalls that about 10 seconds prior to blacking out she felt nauseated, began sweating, and became pale. When she recovered, she had no memory loss or confusion. Her physical examination, including a thorough neurologic examination, is unremarkable. A CBC, blood profile, and EKG are all within normal limits. Appropriate management at this time would include
a.an EEG
b.24-hour Holter monitoring
c.echocardiography
d.a CT scan of the head
e.reassurance

e- Patients with vasovagal syncope often present with prodromal symptoms such as nausea, diaphoresis, pallor, and lightheadedness. This often occurs in stressful or frightening situations. These premonitory symptoms often occur before the loss of consciousness. A quick recovery of mental function after an episode of loss of consciousness makes it much more likely that this was a syncopal episode rather than a seizure, as seizures are often followed by a postictal period of residual confusion. A patient does not always have to experience tonic-clonic movements for the diagnosis to be a seizure disorder, since brief tonic-clonic movements can be seen in some syncopal episodes. However, patients who experience an aura or incontinence of urine or feces often have had a seizure.



For a pregnant woman in the 26th week of gestation who tested positive for Streptococcus B you should start the treatment:
a.right away
b.one week before delivery
c.24 hours before delivery
d.during delivery

d- Physicians who culture for GBS carriage during prenatal visits should do so late in pregnancy (35-37 weeks’ gestation); cultures collected earlier do not accurately predict whether a mother will have GBS at delivery.



You diagnose acute pancreatitis in a 45-year-old white male. As you initiate therapy and closely monitor his progress, which one of the following complications is most likely to develop?
a.Hypomagnesemia
b.Hypoglycemia
c.Hypercalcemia
d.Acute hypertension

a- Treatment strategies for pancreatitis vary somewhat and are related to the degree of inflammation. In patients with mild pancreatitis, a therapeutic regimen of avoidance of oral intake, intravenous hydration, and analgesia usually suffices.
However, patients with more severe pancreatitis are likely to develop significant complications, and require closer monitoring. Patients with hypotension and vascular instability frequently require massive fluid resuscitation. Patients with metabolic complications such as hyperglycemia, hypocalcemia, or hypomagnesemia may require insulin, calcium, or magnesium supplementation.




Immediate gastric lavage is contraindicated in treating acute ingestion of which one of the following?
A.Salicylates
B.Strychnine
C.Ethanol
D.Acetaminophen
E.Phenothiazines

b- Ten to 30 minutes after ingestion of strychnine, untoward symptoms begin. Often without any warning the patient falls into violent convulsions. Gastric lavage is postponed until treatment designed to prevent the convulsions is started. Initiation of gastric lavage as soon as possible is indicated in treating poisoning by salicylates, ethanol, acetaminophen, and phenothiazines.



Which one of the following depressed patients is most likely to commit suicide?
a.A 26-year-old male who repeatedly denies any thoughts of suicide
b.A 30-year-old female who has been hospitalized overnight on several occasions for attempted suicide
c.A 50-year-old recently divorced alcoholic male who feels life is hopeless
d.A 50-year-old female who thinks of suicide and fears she might act on her thoughts

c- Assessment of suicidal risk is critical in determining the need for and duration of hospitalization of depressed patients. Most suicides are planned, not impulsive, and carried out successfully most often by the elderly, males, those in poor health, alcoholics, schizophrenics, those who have recently lost a loved one (especially a mate), and those suffering from depressive disorders. Many depressed patients think about suicide, and a physician should take these patients seriously; however, among this group of patients, the 50-year-old recently divorced alcoholic male has the highest risk of successful suicide.



Which disease could be with higher BP in lower extremity than in upper extremity?
TAKAYASO: High in the lower


A 70-year-old former shipyard worker, who smokes one pack of cigarettes daily, notes progressive weight loss and debility over a period of 6 months. Over a period of 1 month, he develops right chest pain and a nonproductive cough. A chest x-ray reveals extensive pleural thickening, pleural effusion, and hilar adenopathy. A pleural biopsy confirms mesothelioma. Which of the following is a favorable prognostic factor in this patient?
a. Male sex
b. Extent of disease at diagnosis
c. Good performance status
d. Pain as presenting symptom
e. Age over 65
f. None of the above

f- All of the clinical components noted exhibit very poor prognostic factors in the patient with mesothelioma, a particularly aggressive disease that remains unresponsive to many forms of aggressive therapy.



Which one of the following has proven most useful for breast cancer screening in women who have had silicone breast implants?
a.Thermography
b.Ultrasonography
c.Mammography
d.Magnetic resonance imaging

c- Screening by conventional film-screen mammography, supplemented by the displaced or Eklund view, is the recommended method for breast cancer screening in women with breast implants. The displaced view draws the breast forward while placing the implant posteriorly, increasing the amount of breast tissue visualized. None of the other modalities has proven useful for screening asymptomatic women for breast cancer.




A 55-year-old woman has had profuse watery diarrhea for 3 months. Laboratory studies of fecal water show the following:
Sodium: 39 mmol/L
Potassium: 96 mmol/L
Chloride: 15 mmol/L
Bicarbonate: 40 mmol/L
Osmolality: 270 mosmol/kg H2O (serum osmolality: 280 mosmol/kg H2O)
The most likely diagnosis is
A villous adenoma
B lactose intolerance
C laxative abuse
D pancreatic insufficiency
E nontropical sprue

The answer is A
In the case described, the osmolality of fecal water is approximately equal to serum osmolality. Furthermore, there is no osmotic "gap" in the fecal water; the osmolality of the fecal water can be accounted for by the stool electrolyte composition: {2 × [(Na+) + (K+)]} = [2 × (39 + 96)] = 270. A villous adenoma of the colon typically produces a secretory diarrhea. Lactose intolerance, nontropical sprue, and excessive use of milk of magnesia produce osmotic diarrheas with osmotic "gaps" caused by lactose, carbohydrates, and magnesium, respectively. Pancreatic insufficiency causes steatorrhea, not watery diarrhea.



A 60-year-old white female is scheduled to have a total abdominal hysterectomy. She is currently in good health, but the general surgeon is concerned because the patient had a pulmonary embolus 10 years ago.Which one of the following is most effective for prevention of another embolus?
a.No prophylaxis necessary
b.Impedance plethysmography, 36 and 72 hours after surgery
c.Aspirin prophylaxis
d.Full heparinization after surgery
e.Subcutaneous heparin prophylaxis

e- This patient is considered at high risk for a venous thromboembolism because of general surgery, age greater than 40, and previous history of a pulmonary embolus. In numerous clinical trials, heparin, 5000 U subcutaneously 2 hours prior to surgery, followed by 5000 U subcutaneously every 8 to 12 hours until the patient is ambulatory, has statistically reduced the incidence of deep vein thrombosis. Full heparin therapy is not necessary. Aspirin is not effective, and impedance plethysmography would not prevent thrombosis.



An obviously intoxicated 50-year-old white male is brought to the emergency department after the car he was driving hit a telephone pole. He has a fracture of the femur, and is confused and uncooperative. He is hemodynamically unstable. Initial physical examination of his abdomen does not indicate significant intra-abdominal injury.
Which one of the following would be best for determining whether laparotomy is needed?
a.Peritoneal lavage
b.Contrast duodenography
c.Ultrasonography of the abdomen
d.An MRI scan of the abdomen
e.A CT scan of the abdomen

a- Physical examination of the abdomen is often unreliable for detecting significant intra-abdominal injury, especially in the head-injured or intoxicated patient. In a hemodynamically unstable patient with a high-risk mechanism of injury and altered mental status, peritoneal lavage is the quickest, most reliable modality to determine whether there is a concomitant intra-abdominal injury requiring laparotomy. Computed tomography of the abdomen and contrast duodenography may complement lavage in stable patients with negative or equivocal lavage results, but in an unstable or uncooperative patient these studies are too time-consuming or require ill-advised sedation. Ultrasonography may also complement lavage in selected patients, but its usefulness is limited in the acute situation. Magnetic resonance imaging is extremely accurate for the anatomic definition of structural injury, but logistics limit its practical application in acute abdominal trauma.



A 67-year-old white male retired factory worker was found to have an abdominal aortic aneurysm on routine physical examination. A vascular surgeon has recommended operative repair. The patient is a former smoker, with a 10-pack-year smoking history. Three years ago, while under the stress of a forced retirement, he had angina which responded well to sublingual nitroglycerin. He has had no angina for 1 year.
Which one of the following conditions would be the most likely cause of perioperative death in this patient?
a.Pulmonary complications
b.Peripheral embolization
c.Operative site infection
d.Myocardial infarction
e.Cerebral infarction

Answer is d. Myocardial infarction is the major cause of perioperative death in patients undergoing surgery for abdominal aortic aneurysm. This is especially true of patients with a history of known coronary artery disease or with EKG abnormalities, and it is true even if the coronary artery disease is stable.
Cerebral infarction occurs infrequently, even though cerebral vascular disease is commonly present in this patient group. Operative site infection, peripheral embolization, and pulmonary complications are all significant postoperative complications which may cause death, but they are less frequent causes of death than myocardial infarction.




Which one of the following is true of a pregnant patient who has diabetes mellitus?

a. Adjustments in hypoglycemic medications are best made by following urine glucose readings
b. Oral hypoglycemic agents are useful during pregnancy in patients with mild diabetes mellitus
c. A precise knowledge of fetal age is important to a successful outcome for the fetus
d. Because the fetal pancreas helps control the diabetes, ketoacidosis is less likely during pregnancy

c- Ideally, the child of an overtly diabetic woman should be delivered close to term. Precise knowledge of fetal age (by menstrual history, accurate measurements of uterine height during the second trimester, and confirmation by sonography) is very important to a successful outcome for the fetus.



Severe growth retardation is diagnosed in the fetus of a 19 y/o unmarried white female at 36 wks gestation. The Dx is based on biparietal diameter and there is scant amniotic fluid.Which one of the following is the most appropriate management?

a. Perform serial L/S ratios until greater than 3.0, followed by prompt delivery
b. Induce labor, with careful fetal monitoring
c. Perform an immediate C/S
d. Follow the mother weekly with serial ultrasounds
e. Follow the mother weekly with NST

b- Appropriate management of the preterm infant who is severely growth retarded depends on several factors. Generally those near term should be delivered promptly. By the time that growth retardation has become severe, the fetus is usually mature enough to survive if delivered promptly. However, the fetus must be monitored carefully during labor, with facilities for immediate cesarean section if there is deterioration, and the neonate must receive excellent neonatal care beginning immediately after delivery.




A 53 y/o woman presents with a long Hx of dyspepsia, fullness, and belching. An endoscopy shows severe antral erythema and a small hiatal hernia, but no ulcer. Because of her long history of dyspepsia, a serum gastrin test and serum IgG test for Helicobacter pylori are done. The serum gastrin test result is 1800 pg/mL and the test for H. pylori is negative. The next test that should be done in this patient is:
a- push enteroscopy
b- secretin stimulation test
c- gastric acid level messurement
d- pancreas angiography
e- endoscopic US

answer is c. the finding of a high serum gastrin concentration is not infrequently a reason for referral for tests to diagnose Zollinger-Ellison syndrome, she does not have any of the features of the ZE, (recurrent multiple peptic ulcers and/or diarrhea). The first test that should be done is to assess whether the patient has hyperchlorhydria or hypochlorhydria by inserting a NGT and measuring basal acid secretion. However, some of the highest serum gastrin concentrations are found in patients with achlorhydria or hypochlorhydria due to gastric atrophy (for example, in pernicious anemia or after the prolonged use of antisecretory drugs, particularly proton-pump inhibitors).






A 42 y/o female with Hx of 3 spontaneous abortions presented with pain in the left leg, which later on Dx of DVT was confirmed. Which of the following findings is most likely in the laboratory results of this patient?
A - Polycytemia
B - Thrombocytopenia
C - Low white blood cell count
D - Hyponatremia
E – Hyperkalemia

b- In this patient with confirmed DVT and remarkable Hx of the spontaneous abortions, is highly suggestive of antiphospholipid antibody syndrome (antibodies directed against either phospholipids or plasma proteins bound to anionic phospholipids). Most common symptoms are venous and arterial thrombosis, recurrent fetal losses, and thrombocytopenia. Other possible findings include livedo reticularis, migraine headaches, Raynaud’s disease, hemolytic anemia, neurologic dysfunction, renal disease, pulmonary hypertension, avascular necrosis, and adrenal insufficiency.




A 53 y/o male smoker presented with a 2 wk Hx of expectorating sputum streaked with a blood. He denies any fever or chills or increases in the intensity of his cough. P/E and CXR are unremarkable. Which of the following is an appropriate next step in the diagnostic work-up of this patient?
A - Fiberoptic bronchoscopy
B - MRI of the chest
C - High resolution CT of the chest ( HRCT )
D - A and B
E - A and C

Answer is E. Fiberoptic bronchoscopy and HRCT are complementary to each other. HRCT can demonstrate all tumors seen on bronchoscopy as well as several which are beyond bronchoscopic range. On the other hand, HRCT could not detect bronchitis or subtle mucosal abnormalities that could be seen on bronchoscopy. Also, HRCT is particularly useful in diagnosing bronchiectasis and aspergillomas, while bronchoscopy is diagnostic of bronchitis and mucosal lesions such as Kaposi’s sarcoma. The patient in question is at high risk for pulmonary carcinoma; as of today, the procedures are considered complementary in this setting.




A patient with cytomegalovirus retinitis has been treated with IVganciclovir for the last 4 months. On the most recent lab findings a sudden drop in the plt count was noted (20,000 mm3). Which of the following is the most appropriate action in this situation?
A - Discontinuation of the therapy
B - Exchange of ganciclovir with intravenous foscarnet
C - Exchange of ganciclovir with acyclovir
D - Exchange of ganciclovir with valcyclovir
E - Continuation of ganciclovir therapy

Answer is B. The major drugs that are used for treatment of CMV retinitis are IVganciclovir and foscarnet, oral ganciclovir, intraocular ganciclovir, and IV cidofovir. Ganciclovir and foscarnet have equivalent efficacy against the retinitis. Major side effects of the ganciclovir are neutropenia and thrombocytopenia (limiting use in up to 16% of patients). Ganciclovir should not be given with absolute neutropenia of less than 500 mm3 and thrombocytopenia 25, 000 mm3.



A 76 y/o man is hospitalized with stroke in the area of the right middle cerebral artery. He had a paroxysm of cough immediately after attempt to eat.On P/E he is alert and oriented to time, place, and person. He has severe dysarthria but no signs of aphasia. He has facial asymmetry due to Lt sided facial droop, but his gag reflex is intact. Which of the following is the most appropriate way to provide nutrition to this patient?
A - Placement of a percutaneous gastrostomy tube
B – IV alimentation
C - Feeding through a NGT
D - Oral feeding supervised by a nurse and suctioning as needed
E - Clear liquid diet with advanced diet as soon as possible depending on patient’s clinical status

Answer is B. After a stroke about 25-45% of all patients develop dysphagia. The main problem that stems from dysphagia is aspiration pneumonia, which, if it develops, greatly complicates the clinical course and contributes to mortality. The patient in question had an attack of cough after an attempt to eat. This is a common sign of dysphagia. Physical examination of this patient revealed several findings that suggest dysphagia (facial nerve paresis and dysarthria). It is a common misconception that presence or absence of a gag reflex correlates with the risk of aspiration. This is not true. More important in the assessment of the aspiration risk are speech articulation, ability to swallow, and tongue movement.



A 16 y/o male in good health presents to you for a school physical. His family hx reveals that his father died of colon cancer at age 37. Your physical exam reveals a healthy young man with several lipomas on his back and legs and a nodule on his jaw. You should:
a. Suggest colonoscopy at age 30.
b. Suggest colonoscopy now.
c. Suggest flexible sigmoidoscopy and barium enema at age 30.
d. Suggest flexible sigmoidoscopy and barium enema now.
e. Biopsy his jaw lesion.

Answer is D. case of Gardner’s Syndrome.



An elderly male complains of severe muscle weakness in his thigh muscles and proximal arm muscles, although this weakness is mild. He states that his weakness is worse in the morning immediately after getting out of bed and improves during the day.
On P/E, it is apparent that muscle strength increases with repetition of the grip strength test and later diminishes. Which of the following tests should be included in the workup of this patient?
A - CXR
B - Tensilon test
C - Abdominal CT
D - Colonoscopy
E – Cystoscopy

Answer is A. Symptoms in this man are consistent with Eaton-Lambert syndrome. This syndrome shares the same pathologic site with myasthenia gravis (the neuromuscular junction) and has a similar path physiology (an autoimmune disease). Eaton-Lambert syndrome is usually associated with malignancy. Up to 70% of these patients have associated small cell lung cancer, and this disease must be ruled out in every patient with presenting symptoms of Eaton-Lambert syndrome.
Clinical presentation of the Eaton-Lambert syndrome includes weakness that is typically seen early in the hip girdle, making it difficult for the patient to rise from a chair or to climb the stairs. Less dramatic is shoulder girdle weakness. Involvement of the bulbar muscles or diplopia is rare, but ptosis is frequently seen. Symptoms are also likely to be more prominent in the morning; autonomic dysfunction may cause erectile dysfunction and dry mouth.
Differentiation from myasthenia gravis may be hard since patients with Eaton-Lambert syndrome have a positive AChR-Ab test in 13% of cases.



A 50 y/o man presents to the ER complaining of 6 hours of severe diarrhea. He has had eight to ten liquid stools, without blood. He has diffuse cramping abdominal pain alleviated by each bowel movement, but he denies tenesmus. He has mild untreated hypertension but no other medical problems. He denies recent travel. Other family members have not been ill. Vital signs: PR= 94/min, BP= 148/96 mm Hg, no changes with standing, T= 37 °C (98.6 °F). The P/E is normal. The best initial approach to this patient is:
(A) Obtain stool specimens for culture, examination for fecal leukocytes, and examination for ova and parasites
(B) Empiric antidiarrheal therapy
(C) Empiric antibiotic therapy with trimethoprim–sulfamethoxazole or ciprofloxacin
(D) Reassurance and oral fluids
(E) Flexible sigmoidoscopy with mucosal biopsy

Answer is D. This patient has an acute diarrheal illness without evidence of severe inflammation, dehydration, or other risk factors. The great majority of acute diarrheal illnesses are infectious (viral or bacterial) and self-limited. Oral hydration and reassurance are the most appropriate care for such patients. If the diarrhea persists or if the patient develops a more toxic clinical picture, additional diagnostic tests would be indicated. At the time of presentation, stool studies are not helpful. Empiric therapy with antibiotics is not indicated. Flexible sigmoidoscopy is indicated only in persistent or inflammatory diarrhea.



A 9 y/o girl is brought to the clinic because she has felt "sick" and has been unable to go to school for the past 2 days. She complains of a headache, congestion, rhinorrhea, and double vision. Her PMH is remarkable for recurrent otitis media 2 years ago for which she eventually received bilateral myringotomy tubes. She lives at home with her mother and grandmother who are both cigarette smokers. T=38.8 C (101.8 F), PR=120/min, RR=20/min, and visual acuity is 20/20 in both eyes. P/E shows tympanic membranes with evidence of previous surgery, but are otherwise normal, an erythematous oropharnyx with exudation, and slight exophthalmos of the left eye. On the left, the ocular examination also demonstrates periorbital edema, injection of the conjunctiva, trace restriction of extraocular movements, and an afferent pupillary defect. The right eye is normal. The rest of her physical exam is unremarkable. What’s the best next step in Mx?
A. A CT of the head
B. Gentamycin eye drops treat most cases, but patients need close observation
C. Hospitalization and IV antibiotics are indicated
D. Oral antibiotics are the first line of treatment
The correct answer is C. This patient has orbital cellulitis. Patients present with lethargy, fevers, signs and symptoms consistent with sinusitis, proptosis of the globe, restriction of extraocular movements, periorbital edema, injected conjunctiva, and afferent pupillary defects. Hospitalization and IV therapy should be started at once as this condition is potentially fatal, especially if the cavernous sinus becomes involved.


A 37 y/o woman with a history of bipolar disorder is brought to the ER by ambulance obtunded and ataxic. The patient has not been hospitalized in over 5 years and has been stably maintained on outpatient therapy with a regimen of lithium carbonate 600 mg by mouth twice a day. While you are examining her, she has a tonic-clonic seizure lasting approximately 30 seconds. As part of the laboratory work-up, the patient's lithium level is found to be 4.2 mEq/L. After basic airway and cardiovascular support, the most appropriate next step in this patient's management is to:
A. administer a loading dose of phenytoin
B. get a renal consultation for emergent dialysis
C. order an MRI of the patient's head
D. provide conservative management including fluid and electrolyte replacement
E. send liver function tests

The correct answer is B. The patient presents to the ED with potentially life-threatening lithium toxicity. The treatment of choice for lithium levels greater than 4.0 mEq/L is hemodialysis.



A 16 y/o girl is brought to see you by her mother, who is a nurse in your office. The patient is hoping to play for the school volleyball team and needs a clearance form signed by a doctor. Her past medical history includes exercise-induced asthma and allergic rhinitis for which she takes albuterol and loratadine. During the interview with the patient, while you are speaking with her alone, she reveals that she has been sexually active with her boyfriend for the last 2 years. She has not yet discussed this fact with her parents. Her physical examination, including pelvic exam, is normal. At this time the patient should be screened for :
A. chlamydia
B. gonorrhea
C. hepatitis B
D. HIV
E. herpes simplex
F. syphilis
The correct answer is A. Routine screening for chlamydia in all sexually active women aged 25 and younger, as well as in asymptomatic women older than 25 who are at high risk is recommended.



An 18 y/o boy is brought to the ED by ambulance. He and his friends were ice-skating on a frozen pond when the ice broke and the young man became submersed in cold water. His friends admit to drinking alcohol prior to the incident. The patient's rectal T=33 C (91.4 F), PR= 57/min & weak, BP= 80/30 mm Hg, and RR= 7/min. P/E reveals a comatose young man. An EKG is most likely to show
A. delta wave
B. diffuse broadening of T waves
C. prominent U waves
D. shortened QT intervals
E. upward deflection following the S wave

The correct answer is E. Hypothermia prolongs repolarization causing an upward deflection following the S wave (distinctive convex elevation of the J point), which is usually called an Osborn wave (or J wave of Osborn).



A 71 y/o woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of RUQ abdominal pain and then she complained of chills, nausea, and some vomiting. On P/E reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in theRUQ, along with muscle guarding and rebound. T= 40 C (104 F). Lab results :
WBC= 22,000/mm3 with multiple immature forms,
bilirubin= 5 mg/dL and
Alk Ph= 840 U/L.
serum amylase= normal.
An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?
a- Elective cholecystectomy
b- Emergency decompression of the common duct
c- Emergency cholecystectomy
d- Emergency surgical exploration of the common duct
e- Emergency transhepatic cholecystostomy

The correct answer is B.
The Dx is acute ascending cholangitis. This deadly disease is seen in patients with long-standing gallstones who get one or more stones in the common duct, where they produce partial obstruction that allows ascending infection. The chills, very high fever, and extremely elevated alkaline phosphatase are diagnostic. The key component of therapy is immediate decompression of the common duct, which is full of pus. How it is achieved is less important. ERCP is usually the first choice, but it can be done by PTC or by open surgery.



33 y/o woman G3P2, with Hx of two preterm deliveries, comes at 32 wks gestation with contraction every 4 min & 3 cm cervical dilation. A tocolytic drug administered which raised her serum Glc from 95 to 170. What was the pharmacologic agent ?
a- Terbutaline
b- Magnesium sulfate
c- Indomethacine
d- Nifedipine
e- Meperidine hydrochloride

The answer is a- Terbutaline. It’s a beta 2 agonist which relaxes the smooth muscle of uterus and it’s SE is raising blood Glc through glycogenolysis.



An febrile 53 y/o woman developes hypotension, tacchycardia & oliguria 24 hrs after abdominal cholecystectomy. Her skin is cold & clammy. Which of the ffg is most responsible for her symptoms?
a- Gram (-) sepsis
b- Hemoperitoneum
c- Acute MI
d- Pulmonary embolus
e- Pneumothorax

Answer is b- hemoperitoneum. She shows classic symptoms of hypovulemic shock.



A 6 month old child falls and hits his head. Which of the following signs would be the MOST indicative of serious neurological injury?
a- The parent states the child was pale and sweaty for a few minutes after the fall
b- A single post-fall episode of emesis
c- Lethargy immediately after the head injury
d- Hypotension
e-A single grand mal seizure immediately after the fall

Infrequently, infants become hypotensive from blood loss into either the subgaleal or epidural space after head trauma. Hypovolemia can occur because of open cranial sutures and fontanelles. Transient paleness, lethargy, diaphoresis, and emesis are common after minor head trauma and do not necessarily signify significant neurological injury. Persistence of any of these signs or symptoms, or change in mental status is concerning. Seizures may occur shortly after head injury and are usually self-limited. However, about 50 percent of patients with posttraumatic seizures have positive findings on head computed tomography (CT). Children with two or more seizures or a GCS < 8 should be strongly considered for anticonvulsant therapy.



Which of the following drugs is NOT associated with acute pancreatitis?
(A) Heparin
(B) Furosemide
(C) Rifampin
(D) Salicylates
(E) Warfarin

The answer is A. Drugs and toxins are major causes of acute pancreatitis. Some of the medications associated with the occurrence of acute pancreatitis are oral contraceptives, estrogens, phenformin, glucocorticoids, rifampin, tetracycline, isoniazid, thiazide diuretics, furosemide, salicylates, indomethacin, calcium, warfarin, and acetaminophen. Other etiologic factors contributing to the development of pancreatitis include infection, collagen vascular disease, metabolic disturbances, and trauma.



An 11 y/o boy is rushed into the ED following a MVA. The patient was a restrained, front seat passenger, when an oncoming car hit the passenger side of the car. The boy denies loss of consciousness, but in the hospital he complains of pain over his right side. His BP=118/59, PR=139/min, and RR=24/min. On P/E, he has decreased breath sounds over the right base, and there is ecchymosis over the right flank. His abdomen is soft with tenderness in the RUQ. Appropriate Mx of his airway with neck stabilization is provided and he is resuscitated appropriately. Imaging studies of his neck are negative and a CXR does not show pneumothorax or rib fractures. Dipstick of spontaneously voided urine is positive for blood. U/A confirms the presence of 50 RBC/hpf. In regards to his hematuria the next most appropriate course of action is to:
A. begin empiric antibiotic therapy
B. obtain a CT scan of abdomen and pelvis
C. order a renal/bladder ultrasound
D. perform a retrograde urethrogram
E. place a Foley catheter
F. repeat the urinalysis
G. schedule an outpatient intravenous pyelogram (IVP)
The correct answer is B. obtain a CT scan of abdomen and pelvis.
The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT scan is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma. Not only does this child have microscopic hematuria (an indication by itself to perform imaging studies), but he also has signs, (flank ecchymosis and tenderness), that raise the suspicion of renal injury. High suspicion for renal injury (i.e., rib fracture, flank contusion, deceleration injury) is another indication for perform imaging studies.

*** A 45 y/o woman presents with acute pancreatitis with a serum amylase concentration of 2010 U/L, T=37.2 °C (99.0 °F), the leukocyte count is 12,000/mL; plasma Glc=250 mg/dL; and serum ca=8.4 mg/dL. She recovers after 1 wk of supportive therapy. No obvious cause for the pancreatitis is found; ultrasonography is normal, and the fasting serum triglycerides are 350 mg/dL. The best course of action to diagnose the cause of the pancreatitis is:
(A) ERCP
(B) No further diagnostic testing until another attack occurs
(C) CT scan with contrast
(D) Measurement of serum CA 19-9
(E) MRI of the pancreas
B- No further diagnostic testing until another attack occurs
The best course of action in a patient with a first attack of relatively mild pancreatitis even with a high serum amylase concentration is to see whether further attacks occur before continuing invasive investigations. The presumption is either that the patient has passed a small single gallstone or that the cause has not yet been identified, that is, it is “idiopathic pancreatitis.” The latter is often a once-only disease, and therefore no further investigations are warranted at this time. An ERCP and CT scan or MRI would be indicated after recurrent mild attacks or two severe attacks to try to establish a diagnosis, particularly common duct stones or pancreas divisum. Measurement of CA 19-9 is not indicated.
Although a full lipid workup in this patient would be good medicine and should be done in any case (and may also be an indirect evidence of gallstones), it is unlikely to be the cause of pancreatitis. Hyperlipidemic pancreatitis is unusual if lipid levels are less than 600 mg/dL. After an initial severe attack, some authorities would do a repeat ultrasound within 3 to 6 months just to exclude gallstones.


***1- An African- American couple with no known family hx of sickle cell dis., want to know what the chance is that their child have sickle cell dis. To obtain a more accurate assessment, RBC electrophoresis of the couple was done. The male has no HbS, but the female has a clear HbS band. Knowing that the carrier rate among African-Americans is approximately 8%, or 1 in 12, the chance that their child will have sickle cell dis. Is most likely which of the following?
a- 0
b- 1/144
c- 1/288
d- 1/576
e- 1/1936


2- If there was no information about the parent electrophoresis, what would be the chance of the child having the dis.?
a- 0
b- 1/144
c- 1/288
d- 1/576
e- 1/1936

1- a- 0, 2- d- 1/576
Px with sickle cell dis., are homozygous for the HbS. Because only one potential parent has the HbS allel, the only way their child could inherit two HbS genes is if the father’s sperm underwent a new mutation, which is an extremely unlikely event. Therefore, their child does not have a chance of inheriting the dis. Howerever, there’s a chance of ¼ that their child would be a carrier, having only the sickle cell trait.
With no information, the odds that two carriers will meet is 1/12 x 1/12= 1/144, and the odds that two carriers will have an infected child is ¼, so, the odds that two Africa-americans will have a child with dis. is 1/144 x ¼= 1/ 576




***A 28 y/o woman, G4P4, at 28 wks gestation, presents for prenatal visit. She says that she has not felt the baby move for 2 days. She has a Hx of HTN, which she’s being treated with alfa methyl dopa, BID. On P/E, BP= 145/85, fundal height at 30 cm, and baby’s in transverse position. No FHR was detected with Doppler feotoscope. What’s the next step of Mx ?
a- Perform a NST
b- Perform an amniocentesis
c- Obtain real-time US for cardiac motion
d- Obtain a maternal abd. x-ray for fetal assessment
e- Obtain a quantitative beta HCG
f- Observation and check up in 2 wks

Answer is c- Obtain real-time US for cardiac motion
It’s the method of choice for fetal death.


*** A 9 y/o boy presents with confusion & decreased school performance, he soon developes a spastic gait with dysarthria, dysphagia & visual loss. MRI shows massive white matter demyelination in the post. hemisphere. What’s the most likely Dx?
a- MS
b- Metachromic leukodystrophy
c- Adrenoleukodystrophy
d- Subacute sclerosing panencephalitis
e- CJD

Answer is c- adrenoleukodystrophy which is an x-linked dis. that affects young males, usually begin at 7-8 yrs of age. It’s characterized by demyelination of the CNS, adrenal insufficiency, mental deterioration, aphasia, apraxia & dysarthria. 1/3 of patients have loss of vision also.



*** An elderly Px developes painful swelling of Rt. parotid gland 10 days after cholecystectomy. This is most likely secondary to which of the ffg ?
a- Staph. Aureus
b- Duct obstruction by a stone
c- A viral infection
d- Hemorrhage
e- An immunologic reaction

Answer is a- staph aureus.
The px most likely has acute surgical parotitis ( sialadenitis ), which usually occur 1 wk post op in elderly patients who have poor dental hygiene and have intubated. Staph aureus is the most common organism. Tx is surgical drainage & antibiotics.




Which of the ffg can confirm the Dx of gastroparesis?
(A) Endoscopy
(B) Upper gastrointestinal series
(C) Ultrasonography
(D) Nuclear medicine scintigraphy
(E) Electrogastrography

Answer is D- nuclear medicine scintigeraphy
There are no specific signs and symptoms of delayed gastric emptying, and when this disorder is suspected, the diagnosis of gastroparesis can usually be made by various diagnostic methods.
The presence of retained food in a dilated stomach at the time of upper gastrointestinal contrast studies or detected endoscopically is indicative of underlying motor dysfunction when mechanical obstruction has been excluded. However, some patients with decreased motility of the stomach may not exhibit retained food.
Ultrasonography has been used to determine the emptying rate for liquids and appears to be relatively accurate, but gastric scintigraphy of either solid or liquid test meals labelled with a radiopharmaceutical has proven to be the most accurate method of detecting underlying gastric motility abnormalities. Gastric scintigraphy supplies a quantitative result and can be used to evaluate the response to therapy. Electrogastrography is a research tool and its clinical application is unclear.


A 53 y/o alcoholic man with known cirrhosis presents with recent onset of abdominal swelling and fever. On P/E PR=92/min, BP=98/62 mm Hg, T=38.5 °C (101.3 °F), palmar erythema, spider angiomata, moderate abdominal swelling with bulging flanks, and a liver span of 8 cm are noted. There is no evidence of asterixis. Lab results:
ALT=55 U/L, AST=62 U/L, serum BR=1.3 mg/dl, serum total pr.=7.3 g/dl, serum Alb=3.8 g/dl
Paracentesis reveals 25 mL of straw-colored fluid. Ascitic fluid albumin is 2.9 g/dL; the fluid contains 1000 RBC and 960 leukocytes/microliter, with 90% lymphocytes and 10% PMN. The fluid is negative for amylase, and Gram stain shows no organisms.The most appropriate next intervention is:
(A) Cefotaxime, 1 g every 6 hours intravenously
(B) Laparoscopy with biopsy and culture of peritoneal lesions
(C) CT scan
(D) Norfloxacin for prophylaxis of spontaneous bacterial peritonitis
(E) Exploratory laparotomy
Answer is B- laparascopy ewith Bx & culture of peritoneal lesions
This patient has evidence of chronic liver disease on physical examination. The recent onset of ascites is complicated by fever and an elevated number of ascitic fluid leukocytes with a lymphocyte predominance. The ascitic fluid lymphocytosis is typical of tuberculous peritonitis, peritoneal carcinomatosis, or chylous ascites. In spontaneous bacterial peritonitis, the absolute polymorphonuclear cell count is 250/L and represents over 70% of the total leukocytes.
This patient is at increased risk for tuberculous peritonitis because of the debilitating conditions of alcoholism and cirrhosis. The most sensitive procedure for diagnosing suspected tuberculous peritonitis is laparoscopy with biopsy for culture and histologic examination of peritoneal lesions. This does not require surgical laparotomy. Diagnosis to the underlying cause of fever and ascitic fluid lymphocytosis should take precedence over initiation of diuretic treatment. Cefotaxime therapy is appropriate treatment for spontaneous bacterial peritonitis, which is usually caused by enteric gram-negative organisms or streptococci. Aminoglycosides are to be avoided in these patients because of the risk for precipitating or exacerbating renal insufficiency. After an initial episode of spontaneous bacterial peritonitis, prophylaxis with oral antibiotics that provide selective intestinal decontamination, such as norfloxacin, ciprofloxin, or trimethoprim–sulfamethoxazole, will considerably reduce the incidence of recurrent peritonitis. CT scan is insensitive for diagnosis of infection and is most useful for detecting malignancy, which is not likely in this patient.
CMDT:
Fever may suggest infected peritoneal fluid, including bacterial peritonitis (spontaneous or secondary). In immigrants, immunocompromised hosts, or severely malnourished alcoholics, tuberculous peritonitis should be considered.
The accuracy of the SAAG exceeds 95% in classifying ascites. It should be recognized, however, that approximately 4% of patients have "mixed ascites," ie, underlying cirrhosis with portal hypertension complicated by a second cause for ascites formation (such as malignancy or tuberculosis). Thus, a high SAAG is indicative of portal hypertension but does not exclude concomitant malignancy.
In Western societies, half of patients have underlying cirrhosis and ascites from portal hypertension. In such patients, a diagnosis of tuberculous peritonitis may go unsuspected because symptoms are attributed to the underlying liver disease. A high index of suspicion is required for prompt diagnosis and treatment.
www.sma.org/smj1999/aprsmj99/ahmad.pdf

A LBW infant at 2 months of age is brought because he has not benn eating well. On P/E, he’s pale & tacchycardic, The lungs are clear and there’s no hepatosplenomegaly. CBC shows Hgb= 6 mg/dl, which of the ffg is the most likely cause of anemia in this infant?
a- Megaloblastic
b- Sickle cell dis.
c- Anemia of prematurity
d- Alfa thalassemia
e- Homozygous beta thalassemia

Answer is c- anemia of prematurity, which occurs in LBW infants 1-3 months after birth. Hgb is below 7-10 gr/dl.


You are called to see a 29 y/o woman, who was admitted to the hospital 24 hrs earlier because of a stiff neck and a temperature of 39.7 C (103.4 F). She is presumed to have meningitis, but the results of the CSF analysis are still pending. An LP was performed when she arrived at the hospital and IV antibiotics were started. She is now complaining of a dull, frontal headache that is worse when she is sitting upright and relieved by lying down. V/S: T=39.3 C (102.8 F), BP=110/70, PR= 75/min, RR=18/min. P/E shows nuchal rigidity and there is a palpable purpuric rash on her lower extremities and trunk. Funduscopic examination is unremarkable. The most appropriate next step is to
A. administer sumatriptan, intramuscularly
B. advise her to remain in a horizontal position
C. ask her if she has been drinking red wine
D. order a CT scan of the brain to look for intracranial hemorrhage
E. order an MRI of the brain to look for an intracranial mass
The correct answer is B. advise her to remain in a horizontal position
This patient most likely has a LP headache, which often begins within 24 hours of the procedure. The headache is positional in nature, meaning that it is worse when she is sitting upright and relieved by lying down. It is believed to be due to a loss of cerebrospinal fluid during the lumbar puncture, causing decreases in the cushioning of the brain. Patients should be told to remain horizontal after the procedure to decrease the incidence of this complication. The treatment includes remaining in a horizontal position and possibly intravenous caffeine sodium benzoate. If this is not effective, an epidural blood patch should be performed.


A 28 y/o man comes to the ED because of moderate Lt. shoulder pain that is worse with abduction of the shoulder. He plays baseball occasionally with friends and has noticed that the pain worsens when throwing the ball. He denies any Hx of trauma. On P/E weakness of the shoulder, most pronounced with abduction is noted. A shoulder x-ray reveals no fractures or dislocations. The most appropriate next step in management is to
A. advise patient that he should rest and ice the shoulder
B. order an emergent CT scan of the shoulder
C. order an emergent MRI of the shoulder
D. order an outpatient MRI of the shoulder
E. prescribe nonsteroidal antiinflammatory drugs
The correct answer is D. order an outpatient MRI of the shoulder
Rotator cuff tears are chronic use injuries most common in throwing athletes. The clinical symptoms are weakness and instability of the shoulder. An x-ray may show a subacromial spurring, a high-riding shoulder, or calcific tendonitis. Diagnosis is made by MRI of the shoulder. This is a non-emergent diagnosis and the imaging can be performed on an outpatient basis. Repair is made arthroscopically.



A 17 y/o girl comes to the clinic because of a "reddish bump" on her abdomen. She states that she has had it for as long as she can remember, but her current boyfriend is concerned that it may be "cancer". She has no other complaints and does not take any medications other than ocp for birth control. Her grandfather has malignant melanoma of the eye and her mother has breast cancer. P/E shows a 0.4cm pinkish-brown, raised lesion on the left periumbilical region, 3cm lateral to the umbilicus. A small amount of soft tissue is palpated beneath the lesion. It is directly on an imaginary line that you can trace along the body from the left axilla to the left inguinal region. The remainder of the physical examination is normal. In discussing this lesion with the patient, you should inform her that :
A. coal tar ointment and ultraviolet light therapy is an old but useful treatment
B. she has a 70% chance of having a kidney and/or urinary tract defect
C. the lesion needs to be removed immediately because it is precancerous
D. this is most likely a congenital defect that can be removed for cosmetic purposes
E. this needs to be removed immediately and she will need radiation therapy
The correct answer is D. This patient most likely has an accessory nipple (polythelia) and extraglandular breast tissue (polymastia), which are present in approximately 2% to 5% of the population. They usually occur along the "milk line," which is an embryologic line that extends from the axilla to the inguinal region. Normal breasts form along this line and other areas of breast tissue and accessory nipples can too. Patients often think that they are "moles" and generally are only concerned about the cosmetic appearance. They can be simply removed as an outpatient, and additional treatment is not usually necessary.



A 74 y/o woman comes to the ED because of a 5 hr history of Rt sided weakness. The sudden weakness came on while she was giving her husband a bath. She says that she was sure that she was having a stroke because her husband has had 2 strokes in the past, but her symptoms resolved spontaneously before she arrived at the hospital. She is very concerned about her risk for a stroke because her husband is completely dependent upon her for care. She is able to ambulate normally and has no residual functional loss. BP=110/80 mm Hg, PR=70/min. Funduscopic examination is normal. A thorough neurologic examination is unremarkable. The most appropriate next step is to :
A. advise her to take a daily aspirin
B. auscultate the carotid arteries
C. obtain an MRI of the head
D. order a carotid sonogram with Doppler
E. schedule an elective carotid endarterectomy
The correct answer is B. This patient most likely had a transient ischemic attack, which is a neurologic event that lasts for less than 24 hours. It is often due to atherosclerotic disease and therefore auscultation of the carotid arteries may demonstrate the presence of a bruit, which suggests atherosclerotic disease at the carotid bifurcation. TIAs from carotid disease may occur due to ischemia from stenosis or from an embolization of small plaques from the ulceration of the plaque. The next step in this case is to auscultate the carotid arteries because this is the least invasive, cheapest, and quickest method to detect atherosclerotic disease.



A 92 y/o man is brought to the clinic by his son and daughter who tell you that their father "has gone blind". Further investigation uncovers that his visual loss has been a slowly progressive process with no ocular pain. His son and daughter are concerned because the patient lives alone. The patient does not complain of any difficulty seeing and is agitated that he has been brought to your office. Examination reveals normal vital signs and a visual acuity of 20/400 in both eyes. Pupil examination, extraocular movements, and confrontational visual fields are all normal. A penlight exam of the eye shows a yellow-brown color to the lens in both eyes, but is otherwise unremarkable. Direct ophthalmoscopy is very difficult and a sharp view of the retina is not possible. The family should be advised that:
A. Age alone is a common cause of decreased vision and his level of vision is what you would expect for a patient his age
B. Eye surgery is necessary to prevent total blindness (no light perception)
C. Glaucoma is the most likely diagnosis and prompt ophthalmology consult is indicated
D. He has macular degeneration and low vision aides should be considered to assist with activities of daily living
E. Tell the patient and family that as long as the patient is comfortable with his vision no treatment is necessary
The correct answer is E. This patient has cataracts in both eyes. The typical clinical presentation of a patient with cataracts is that of slowly progressive visual loss. Patients may also complain of difficulty with glare and bright lights. They often note decreased color brightness and contrast sensitivity. On exam, a lens that has a cataract will appear yellow-green to yellow-brown. A mature cataract will present as a white lens and visual acuity of hand motions or light perception. With advanced cataracts, the fundoscopic exam may be difficult or not possible. The treatment for cataracts depends on the level of visual deficit experienced by the patient. Appropriate treatments range from observation/education, spectacles, and cataract surgery. If a patient with cataracts is comfortable with his current vision, then treatment with glasses or surgery is not necessary. Referral to an ophthalmologist may be appropriate for more in depth counseling based on the level of concern of the patient.



A 3 y/o boy is brought to the ED by his parents because of a 24 hr Hx of intermittent, generalized abdominal pain. The parents tell you that he complains of the pain for 10-minute episodes and during these times he refuses to walk, but then he spontaneously returns to his normal activities. This occurred 8-9 times yesterday. Today the symptoms occurred more frequently and were associated with 3 episodes of non-bloody, non-billous emesis so the parents brought him into the hospital. There is no history of fever, constipation, or soiling. On examination the patient appears tired and has mild diffuse abdominal pain. He has guaiac-positive stool. PR=125/min. The study most likely to provide a diagnosis is :
A. an abdominal x-ray
B. a barium enema
C. a CBC with differential
D. a CT scan of the abdomen
E. a LP

The correct answer is B. This patient presents with a very common complaint in the pediatric population, abdominal pain. The key to this case is the quality and frequency of this abdominal pain. The pain was described as being diffuse and intermittent with periods of resolution of the symptoms. This type of pain pattern, along with emesis, the lethargy seen in the emergency department, and the guaiac-positive stools should raise red flags for the diagnosis of intussusception. In intussusception a segment of bowel (most commonly the distal ileum into the cecum) telescopes into an adjacent segment causing obstruction. This obstruction tends to resolve and recur causing the intermittent abdominal pain. The barium enema is diagnostic and in many cases a curative procedure as well and is therefore the study of choice in this case.




A 64 y/o farmer comes to the clinic with an injury to the foot, which happened at his farm 24 hrs ago. He reports that he was working on the farm, when he accidentally stepped on a rusty nail, which penetrated deep into his foot. He took some analgesics and he was feeling well. His wife urged him to come to the clinic. He denies any fever, chills, or rigor. His past medical history is significant for non-insulin dependent diabetes mellitus, which is well controlled with oral therapy. He has no past surgical history. Examination of the foot reveals a deep penetrating wound in the sole of the left foot. There is no associated erythema or induration around the foot. No foreign particles are noted along the edges of the foot, which is tender on palpation. There is no motor or sensory loss. No active bleeding is noted in the penetrating wound. The patient tells you that he had 3 doses of tetanus toxoid injections when he was young. The last tetanus injection was 8 years ago for a similar episode. The most appropriate next step in management is to
A. administer a tetanus toxoid booster injection
B. administer a tetanus toxoid booster injection and human immunoglobulin
C. provide human immunoglobulin
D. provide no additional therapy at this time
E. surgically debride the wound
The correct answer is A. Tetanus prone wounds are any wounds that are over 6 hours old, deep, crushed or penetrated, contaminated with soil, associated with compound fractures, partial or full thickness burns, or human or animal bites. Patients who received 3 doses of tetanus toxoid in the last 5 years do not need further therapy for a tetanus prone wound or for a clean wound. Patients who received a tetanus toxoid between 5-10 years ago and have a tetanus prone wound need booster tetanus toxoid injections, whereas those with a clean wound would need no further therapy. When the last dose of tetanus toxoid was more than 10 years ago, then both clean wounds and tetanus prone wounds need tetanus toxoid booster injections. In addition, those with a tetanus prone wound, whose last dose was more than 10 years ago, need to have human immunoglobulin (choice C) administered.

** A 60 y/o diabetic male is brought to ER by his wife for evaluation. His wife reports that he had developed high fevers 2 days prior, which were attributed to a viral infection and no medical attention was sought. His wife became concerned when the fever persisted despite the use of Tylenol and he became increasingly lethargic.
Vitals: HR=130, RR=24, BP=70/55, T=102F
On examination, he was flushed, warm to the touch, confused, and diaphoretic. Mucus membranes appeared dry. His neck was supple with negative Kernig and Brudzinski signs. His eyes were equal and reactive to light with no papilledema, and his lungs were clear to asculation bilaterally with no evidence of rales, rhonchi, or wheezes. On cardiac exam he was tachycardic with a normal S1 and S2. A flow murmur was heard. The abdominal and neurologic exams were unremarkable. Examination of the dorsal aspect of the right foot revealed foot cellulites. What would be the first appropriate step of treatment in this man?
A. Immediate dose of IV cefazolin (Ancef)
B. Fluid resuscitation with normal saline
C. Drainage and culture of wound site
D. Obtain CBC, Chem 10, ABG, blood cultures, urine cultures, wound culture
E. Stat CT of head

Answer is B.
This patient is in septic shock given his BP of 70/55 and temperature of 102F. In addition, patient demonstrates flushing, which indicates vasodilation, another characteristic of septic shock. This is most likely the result of bacteremia secondary to his foot cellulitis. In hemodynamically unstable patients, airway, breathing, circulation should be assessed and fluid resuscitation should be started immediately. This should be quickly followed by drainage and culture of wound site, urine culture, and bloodwork including: CBC, Chem10, ABG, blood cultures. Furthermore, empiric antibiotics should be started intravenously. In this case, the most common organisms would be Strepococcus and Staphylococcus, making cefazolin (Ancef) would be an appropriate choice.
Mental status changes are often evaluated by CT scan. However, this patient's changes are most likely secondary to his hemodynamic instability and should resolve with resolution of his septic shock.

** A 25 y/o female is brought to ER after being involved in a MVA. She is hypotensive and tachycardic. She has good breath sounds bilaterally. Fluid resuscitation is started immediately with Lactated Ringers solution, and blood is sent for type and cross. She has minor scrapes and lacerations on her torso. She remains hypotensive even after 2L of Lactated Ringers solution and blood transfusion with packed red blood cells is begun. After infusion of 2 units, her blood pressure stabilizes at 110/80 mm Hg. She is placed under observation. 3 hours later she complains of chills, generalized pruritus and difficulty breathing. On exam she is found to have a temperature of 101 F, BP of 110/80, HR 100, RR 20. HEENT is normal. Neck is supple with no JVD. Auscultation of the lungs reveals crackles at the bases. Heart exam is normal. Abdomen is soft, nontender, nondistended, with good bowel sounds, there is no hepatosplenomegaly. Extremities reveal no edema, no cyanosis, and good range of motion. Neurologic exam is unremarkable. Examination of skin reveals a generalized urticarial rash. She is treated with diphenhydramine (Benadryl) and acetaminophen with resolution of symptoms.
In the future, if this patient were to require another blood transfusion, what precautions need to be taken?
A. None
B. Only leukocyte poor packed red blood cells should be given.
C. Only irradiated packed red blood cells should be given.
D. Only CMV negative packed red blood cells should be given.
E. This patient is not a candidate for any further blood transfusions.

Answer is B.
Patient is experiencing a leukoagglutinin reaction. This is an immunologic reaction to antigens present on the white blood cells which are invariably present in the transfused blood products. It occurs most commonly in patients who have been sensitized through previous transfusions or pregnancies. Typical presentation includes fever and chills within 12 hours after transfusion. In addition, cough and dyspnea often occur. Patients respond to acetaminophen and benadryl. Depletion of white blood cells from the blood products can reduce the incidence of future reactions. Pretreatment with acetaminophen and benadryl may also help reduce the recurrence of the reaction.


** A 35 y/o African American female presents to her primary care physician complaining of pain in both legs. The pain started one day ago and got progressively worse. It is localized mostly on the anterior aspect of her legs below the knees. She also complains of malaise and fatigue and thinks she may have a low grade fever. She has no significant past medical or family histories. She takes no medications and is not allergic to any medications. She denies alcohol, tobacco or recreational drug use.
Physical exam is unremarkable except for tender erythematous nodules located on the extensor surfaces of both legs below the knees.
A chest Xray is done,which demonstrates hilar lymphadenopathy with no parenchymal involvement. What’s the most likely Dx?
Answer is sarcoidosis.
Painful red nodules located on the anterior aspect of the legs is typical of erythema nodosum. Erythema nodosum may be associated with various infections such asTB, coccidiomycosis, streptococcosis, hepatitis B, syphilis, and yersinia. It may also be due to drugs such as sulfonamides and ocp. Other diseases that are associated with it include sarcoidosis, rheumatic fever, leukemia, and IBD.
The erythema nodosum in this patient is most likely secondary to sarcoidosis as evidenced by the significant hilar lymphadenopathy. In addition, the incidence of sarcoidosis is highest in African Americans, and women are affected much more frequently than men. Disease onset is commonly in the third or fourth decade of life.


*** A 43 y/o homeless man is brought in by the paramedics after he was found confused and wandering in the streets. On evaluation he is agitated, confused and combative. He is diaphoretic, emanates a foul odor, and his clothes are filthy with evidence of emesis. He has slurred speech, is noted to be talking to people who are not there, and swatting at invisible objects. Upon questioning he makes an incoherent comment about seeing bugs on the walls. He has a generalized tremor and appears fearful of the staff. His vital signs show: BP 135/80, HR 102, RR 20, Temp 99.8 F. His mucus membranes are dry and skin turgor is normal. Chest and cardiac exams are normal. Abdominal exam is significant for slight hepatomegaly. Neurologic exam reveals intact cranial nerves, DTR's are symmetric bilaterally, but he refuses to cooperate with the remainder of the neurologic exam. He is disoriented to person, time and place.
Which of the following changes are consistent with this patient's presentation?
AST ALT MCV [Mg+2] Glucose
A. inc No change No change dec dec
B. inc inc inc dec dec
C. inc inc No change inc dec
D. No change inc No change inc inc
E. No change No change inc No change inc


Answer is B.
This patient is exhibiting signs and symptoms of delirium tremens (DT). DT is organic psychosis, which is usually the result of acute alcoholic withdrawal. It is characterized by mental confusion, tremors, visual hallucinations, diaphoresis, and autonomic hyperactivity. It usually manifests within 25-72 hours after the last drink, but, can occur as late as 7-10 days later. DT tends to occur in individuals with previous withdrawal episodes.
This patient is a chronic alcoholic and alcohol can cause liver damage. As a result he can be expected to have elevated AST and ALT levels. Usually AST is two times more elevated than ALT. Gluconeogenesis in the liver may be impaired resulting in hypoglycemia. In addition, hypoglycemia, hypomagnesemia and an elevated MCV are commonly seen in alcoholics, and are most likely the result of malnutrition.


** A 19 y/o college student with height 5'2" and weight 120lbs is brought to the emergency room after she experienced two episodes of coffee ground emesis. Her vital signs on arrival are normal. On physical exam she has poor eye contact and a blunted affect. She is oriented to person, time and place. Her mucus membranes are moist, front teeth show loss of enamel. She has mildly enlarged parotid glands bilaterally. Her breath has a rancid odor. Her chest and cardiac exam are normal. She has mild epigastric tenderness, good bowel sounds, no distention, no hepatosplenomegaly. Neurologic exam is unremarkable. A nasogastric tube is placed which drains clear fluid after an initial 10ccs of coffee ground material. An upper endoscopy is performed which demonstrates a linear mucosal tear at the gastroesophageal junction and a diagnosis of a Mallory-Weiss tear is made.
From your understanding of the patient's underlying condition, which of the following acid-base abnormalities would you expect?
A. Hypochloremic metabolic alkalosis
B. Hypochloremic metabolic acidosis
C. Hyperchloremic metabolic alkalosis
D. Hyperchloremic metabolic acidosis
E. No abnormalities are expected.

Answer is A
On Hx & P/E , this patient has many concerning signs and symptoms. Her worn-appearing enamel, bilaterally enlarged parotid glands, rancid breath odor, and poor eye contact point to an eating disorder, most likely bulimia nervosa, given her normal height to weight ratio. In addition to her chronic disease, she is acutely experiencing pain secondary to a Mallory-Weiss tear. A Mallory-Weiss tear ia a mucosal tear at the gastroesophageal junction, which arises from events that suddenly raise transabdominal pressure. Examples include sudden lifting, or as in this patient, retching or vomiting. Given this patient's history of retching and vomiting, one would expect her to have hypochloremic metabolic alkalosis, as H+ and Cl- are lost during vomiting.


45 y/o male with atrial rate of 300/min & ventricular response in 2:1 ratio, has been treated with an antiarrhythimc agent, which slowered the atrial rate to 200/min & increased the ventricular rate to 200/min. What was the pharmacologic agent used?
a- adenosine
b- digoxin
c- propranolol
d- quinidine
e- verapamil

Answer is d- quinidine.
Quinidine slowers the atrial rate due to it’s vagolytic action & increases AV conduction. So, an atrial flutter at 200/min was conducted to the ventricles in a 1:1 ratio, resulting in an increase in ventricular rate to 200/min. This effect could be avoided by use of a drug that slows AV nodal conduction like choices a, b, c & e.



Which of the ffg correctly identifies the sequence of cardinal movement of labor that fetus undergoes prior to delivery?
a- descent, ext. rotation, extension, int. rotation, flexion
b- descent, flexion, int rotation, extension, ext rotation
c- int rotation, flexion, descent, ext rotation, extension
d- flexion, extension, int rotation, descent, ext rotation
e- extension, descent, int rotation, ext rotation, flexion

answer is b- descent, flexion, int rotation, extension, ext rotation



35 y/o woman, G3P2, at 39 wks gestation undergoes a vaginal delivery of a 3295 gr male neonate. The placenta was not completely removed & after bleeding she underwent a total abdominal hysterectomy due to placenta accreta & receives 5 unites of packed RBC. Which of the ffg hormones are most likely to be affected by this scenario?
a- ACTH
b- PRL
c- TSH
d- FSH
e- ADH
f- None of the above
g- All the above

Answer is b- PRL due to developing sheehan’s syn.


A 26 y/o woman with recently diagnosed Hodgkin's disease is admitted to the ICU after an overdose of lorazepam and alcohol. She is intubated and stable. Which of the ffg would be expected to help prevent the development of ventilator-associated pneumonia in this patient?
A. Keeping the patient in the semi-recumbent position
B. Routine changes of the ventilator circuit
C. Nasotracheal (as opposed to oral) intubation
D. Prophylactic antibiotics
E. Chest physiotherapy
Answer is A. Keeping the patient in the semi-recumbent position
Ventilator-associated pneumonia accounts for more than 50% of all infections in the ICU. Handwashing, semi-recumbent positioning, kinetic (rotational) bed therapy, and drainage of condensate from ventilator circuits are effective strategies for preventing such infections. However, routine changes of the ventilator circuit and chest physiotherapy are ineffective. There is some evidence to support oral, as opposed to nasal, intubation. Influenza and pneumococcal vaccination, which should be addressed in all patients at the time of hospital discharge, would not affect the development of ventilator-associated pneumonia.

In a patient with steatorrhea, which of the following test results is the most specific for the diagnosis of chronic pancreatitis?
A. Abnormal Schilling test that does not normalize with intrinsic factor
B. A serum carotene value of 25 µg/mL
C. A 72-hour fecal fat content of 30 g
D. A serum trypsinogen value of 5 ng/mL
E. An abnormal 13C triolein breath test
Answer is D. a serum trypsinogen of 5 ng/ml
The serum trypsinogen concentration, when low, is the only test in this group that is specific for pancreatogenous steatorrhea. The other test results are associated with, or diagnostic of, steatorrhea but do not identify specific cause of steatorrhea.
The Schilling test, if abnormal after intrinsic factor, can occur with ileal disease, bacterial overgrowth, or chronic pancreatitis. A low serum carotene concentration, abnormal 72-hour fecal fat test, or abnormal 13C triolein breath test are present with steatorrhea of any cause, for example, small bowel mucosal disease, bacterial overgrowth, chronic pancreatitis, and ileal resection.

A 38 y/o farmer has acute onset of severe, progressive dyspnea associated with cough and weakness. These symptoms occurred 1 hour after the patient had worked in a silo that had been filled with fresh corn silage the previous day. Which of the following is most likely to have caused his acute pulmonary decompensation?
A. Exposure to thermophilic actinomyces
B. Viral pneumonia
C. Pneumothorax
D. Nitrogen dioxide pneumonitis
E. Allergic bronchopulmonary aspergillosis
Answer is D. Nitrogen dioxide pneumonitis
Silo filler's disease results from inhalation of oxides of nitrogen, including nitrogen dioxide, which tends to accumulate at the top of tall storage silos. The oxides of nitrogen are generated soon after the silo is filled with fresh silage that is subsequently used for animal feed. Nitrogen dioxide, when dissolved in the aqueous film that lines the respiratory tract, becomes nitric acid and produces a chemical pneumonitis. When the farmer enters the top of the silo to level the silage or prepare it for mechanical unloading, exposures can be quite high. The chemical pneumonitis of silo filler's disease must be differentiated from farmer's lung, which is an immunologic reaction to molds or thermophilic actinomycetes that grow in hay during the storage season. Exposure to this organic material occurs when farmers spread the hay for animal feed during the winter. Hypersensitivity pneumonitis can then occur 6 to 8 hours after exposure.

Which of the ffg inhalational anesthetics will provide the most rapid rate of recovery?
Blood:Gas partition coefficient min. alveolar concentration (%)
a- nitrous oxide 0.5 >100
b- desflurane 0.4 7
c- sevoflurane 0.7 3
d- isoflurane 1.4 1.4
e- halothane 2.3 0.8
Answer is b- desflurane
With an inhalational anesthetic, both rate of onset & rate of recovery depends on blood: gas partition coefficient, so the lower the coefficient, the recovery time is shorter.

A 7 y/o female is reffered to the physician because of cessation of speech in midconversation, a blank stare & flickering of the eyelids which lasts for 10 seconds and then she resumes regular activity. The physician suspects a seizure disorder and asks the child to hyperventilate, which cuase the symptoms to occur. Which of the ffg is characteristics of this disorder in EEG?
a- hypsarrhythmia
b- an interictal slow-spike wave
c- centrotemporal spikes
d- a 3/sec spike & wave pattern
e- a 6/sec spike & wave pattern
answer is d- a 3/sec spike & wave pattern. ( absence seizure )
hypsarrhythmia -- > infantile spasm
interictal slow-spike wave -- > Lenox- Gastaut syn.
centrotemporal spikes -- > benign partial epilepsy
4-6/sec spike & wave pattern -- > juvenile myoclonic epilepsy

a 2 y/o symptomatic HIV-infected child presents because of exposure to measles. His immunization is up to date. He received IG 6 wks ago, which of the ffg is the most appropriate course of action?
a- Administer monovalent measles vaccine
b- Administer another MMR vaccine
c- Administer IG
d- Administer Vit C
e- Do nothing, because the child is already immunized for measles
Answer is c- Administer IG.
Symptomatic HIV infected children exposed to measles should receive IG prophylaxis regardless of vaccination status, because they have poor immunologic response to vaccine. If a child received IG within 3wks of exposure , no additional IG is required.

A 27 y/o woman with schizophrenia and hx of seizure is stabilized on valproate & then started on clozapine. One wk later, she complains of sedation & sialorrhea. Which of the ffg should be performed immediately?
a- clozapine level
b- prolactine level
c- thyroid function
d- valproate level
e- WBC count
Answer is e- WBC count.
Weekly monitoring of WBC count during Tx with clozapine is required because 1% risk of agranulocytosis. Sedation & sialorrhea are untoward effects of clozapine Tx. Clozapine & valproate level may have clinical significance, but are not immediately required.

A 7l y/o woman presents with pain in the Rt. lateral thigh and buttock. She has had this pain for the last 6 months, and symptoms are aggravated by prolonged standing and walking, and they improve with rest. In recent years, she has also had intermittent LBP, but there has been none in the last 6 months.On P/E, the patient has mild limitation of rotation in both hips but no pain on motion. There is diffuse mild tenderness in the Rt. lateral thigh and buttock. Abduction of the hips against resistance does not increase her pain. The lumbar region of the spine is not tender, but there is moderate increase in lumbar lordosis and in paravertebral muscle tone. Her pain is not increased by bending forward, but there is some increase in pain with full spinal extension. There are no neurologic deficits.What is the most likely cause of this patient's pain?
A. Osteoarthritis of hip
B. Arthritis of sacroiliac joint
C. Trochanteric bursitis
D. Osteoarthritis of lumbar spine
E. Spinal stenosis
Answer is D. Osteoarthritis of lumbar spine.
Referred pain from the lower lumbar facet joints or intervertebral discs is often reported by the patient as hip pain, with localization to the buttock and lateral thigh. The pain is characteristically aggravated by maneuvers that increase the force brought to bear on these joints, particularly spine extension as well as lateral bending or rotation toward the painful side. Pain over the spine may or may not be present, but even in its absence, there may be paravertebral muscle spasm contributing to reduced spine motion. Frequently referred pain may have a different localization from radicular pain at the same level. Lower lumbar nerve root impingement usually causes pain below the knee.
Pain resulting from hip joint pathology is usually felt in the groin and anterior thigh. Hip motion, particularly rotation, is usually painful. Sacroiliac arthritis usually results in constant pain and is particularly severe in the morning and improves with motion. Trochanteric bursitis causes lateral hip and thigh pain, with tenderness over the trochanter. A provocative test designed to increase the pain involves abduction of the hips against resistance; this results in contraction of muscles that attach to the trochanter. The maneuver did not increase pain in this patient. Spinal stenosis causes compression of lumbosacral nerve roots, usually producing bilateral lower leg pain.

A 60 y/o woman has a long hx of subumbilical abdominal pain occurring during periods of stress and sometimes aggravated by ingesting coffee, nuts, or chocolate and by constipation. Recently, the pain has become worse on the left side of the abdomen. The results of barium enema and upper GI series are normal, and a CT of the abdomen and pelvis shows a 3 x 3-cm loculated cyst in the tail of the pancreas. There are no cysts in the liver or kidneys. The results of all blood tests, including the test for amylase, are normal. The best management of this patient is:
(A) Surgical removal of the cyst
(B) Three monthly CT scans to determine whether the cyst enlarges or subsides
(C) Reassurance and no further evaluation
(D) ERCP to determine whether the cyst communicates with the pancreatic duct
(E) Needle aspiration of the cyst and examination of the cyst fluid

Answer is A.
The incidental finding of a pancreatic cyst can be a difficult decision-making problem. In the healthy patient, the best course is to advise surgery. It is almost impossible to distinguish a cystadenoma from a cystic adenocarcinoma or a benign solitary cyst due to chronic pancreatitis from a malignant cyst or mucinous duct ectasia. Because about 20% of these cysts turn out to be malignant, the patient may prefer to opt for one of the other alternatives, for example, three monthly CT scans to determine whether the cyst enlarges, ERCP to determine whether the cyst communicates with the pancreatic duct and this is more likely to be due to pancreatitis, or a needle aspiration of the cyst and examination of the cyst fluid for malignant cells. Clearly, in older patients with multiple medical problems, one might agree to this course before undertaking surgery. However, whatever course is decided upon one should be very wary of telling the patient that they have a small insignificant finding and nothing further needs to be done.


A 57 y/o man with cirrhosis attributable to alcohol and hepatitis C has been treated with diuretics for ascites for 3 months. He has abstained from alcohol for 4 months and has been compliant with a 2-g sodium diet. Medications include aldactone, 300 mg/d, and furosemide, 80 mg twice a day.
P/E shows a moderately wasted, icteric-appearing man with a BP of 105/62 mm Hg, PR of 94/min, and no fever. Chest examination is clear to auscultation and percussion, and the abdominal examination reveals tense, massive distention with shifting dullness and active bowel sounds; the liver and spleen size cannot be determined by palpation. Pitting edema is present to the mid-shins bilaterally. Laboratory studies:
Serum sodium 128 meq/L
Serum potassium 5.0 meq/L
Serum bicarbonate 32 meq/L
Serum chloride 100 meq/L
Serum total bilirubin 3.2 mg/dL
Serum albumin 2.4 g/dL
Blood urea nitrogen 18 mg/dL
Serum creatinine 1.9 mg/dL
Prothrombin time 15.5 seconds

Abdominal ultrasound demonstrates massive ascites, a small diffusely echogenic liver without focal masses or biliary dilation, and splenomegaly.
The most appropriate treatment at this time is:
(A) Addition of hydrochlorothiazide therapy
(B) Total paracentesis with albumin infusion (6 to 8 g/L of fluid removed).
(C) Continue current diuretic therapy and re-educate the patient about dietary salt restriction
(D) Discontinue diuretic therapy and observe
Answer is D.
This patient has decompensated liver disease, has developed tense ascites despite aggressive diuretic therapy with high doses of combined diuretic therapy, and presents with hyponatremia and renal insufficiency. His ascites can be considered diuretic-intolerant because he demonstrates hyponatremia and renal insufficiency on the current regimen. Consequently, continuing the present diuretic regimen is not appropriate; his condition would likely deteriorate further if more aggressive diuretic management with addition of thiazide diuretics were attempted.
Large-volume or total paracentesis is effective in managing refractory ascites. It is recommended that this be performed with albumin infusion (6-8 g/L) to decrease the risk for exacerbation of renal insufficiency. It has been shown that large-volume paracentesis (5 L) can occasionally result in prolonged circulatory dysfunction typified by decreased intravascular volume in cirrhotic patients when performed without colloid infusions. In this patient with marked renal insufficiency, as suggested by a serum creatinine of 1.9 mg/dL in the setting of advanced liver disease and muscle wasting, who has no symptoms attributable to large-volume ascites that necessitate immediate treatment, large-volume paracentesis may result in deterioration despite colloid infusion and should be avoided. Consequently, this patient can be considered diuretic intolerant; discontinuing diuretics and observation is the preferred therapy at this time.

Which of the following can cross the placental membrane ?

a. IgM
b. Insuline
c. Bacteria
d. Methyl Dopa
e. Steroid Hormones

answer is e.



68 y/o man is brought to you in a comatose state, his eyes are in midposition and pupils are pinpoint, what is the most likely location of the hemorrhage?
a. pons
b. putamen
c. thalamus
d. cerebellum
The correct answer is a. pons.
Option b is incorrect, putament hemorrhage cause deviation of both eyes to the side of the lesion (away from hemiparesis), but the sizes of pupils are normal. Option c is also incorrect, in thalamus hemorrhage, although the sizes of the pupils are small; both eyes are deviated inward and look at nose. Option d is also incorrect, patients with cerebellum hemorrhage have a normal size of pupils and they are unable to look toward the side of the lesion.

23 y/o woman presents with excessive hair growth on face, chest, and on the abdomen, her physical and blood examinations are normal, what is the most likely cause?
a. familial
b. ovarian tumor
c. 21-hydroxylase deficiency
d. polycystic ovary syndrome
The answer a. Familial (or idiopathic) is the most common cause of hirsutism. Ovarian tumors are very rare causes of hirsutism (only 0.8%). 21-hydroxylase deficiency causes ambiguous genitalia in baby girls. Polycystic ovary syndrome is suspected in obese women with amenorrhea and a serum LH:FSH ratio greater than 2.0.

A 35 y/o African American man presents to your office for a first time visit. He has no past medical history, and takes a multivitamin daily. He is active and runs approximately 3 miles/wk. He has a 10-pack/yr Hxof smoking and has 1-2 beers/wk.
v/s: T=37 C (98.4 F), BP=110/60 mm/Hg, PR=65/min and regular, and RR=15/min. On P/E, a II/VI systolic ejection murmur at the Rt. upper sternal border is noted that has no respiratory variation, increases in intensity upon going from supine to standing and Valsalva, and decreases in intensity with sustained handgrip. There is a prominent, nondisplaced PMI. The remainder of his examination is unremarkable. The most likely Dx is:
A. aortic stenosis
B. IHSS
C. MR
D. PDA
E. tricuspid regurgitation

The correct answer is B. IHSS
This condition involves an aortic outflow obstruction that is dependent upon both preload and afterload. As preload is decreased (i.e., as with a Valsalva maneuver or moving from supine to erect) the ventricular chamber size is decreased, the degree of outflow obstruction is increased, and the intensity of the murmur is increased. As the afterload is increased (i.e., with handgrip) the end systolic chamber size is increased, the degree of outflow obstruction decreased, and the intensity of the murmur is decreased. The prominent PMI suggests a left ventricle that has hypertrophied in response to the outflow obstruction. The identification of IHSS is important since those with this form of cardiomyopathy are at increased risk for sudden death.



A 57 y/o man with schizoaffective disorder, whose symptoms were in remission until 2 wks ago, is brought to the ED by his girlfriend. He will not talk with you but the girlfriend tells you that he has a hx of "overdoses", and she is afraid he has taken a lot of "his pills". He has been complaining of voices telling him he "should be dead". He has not left the house in a month and has spent several hours a day looking out the window for the "king and savior" to "come take him". His medications include haloperidol, valproic acid, and a small dose of amitriptyline for chronic pain related to nerve damage in his leg, which occurred in a motor vehicle accident 10 years ago. He has no other medical problems. A chart review reveals that he has no allergies and was diagnosed with schizoaffective disorder 30 years ago.
Vitals: T=37.0 C (98.6 F), BP=110/70 mm Hg, PR=70/min, and RR=26/min. He is a depressed appearing man with very poor eye contact. He smells of alcohol. He does not acknowledge you, but will answer some questions for his girlfriend. He does admit to feeling that "life is not worth living" and feeling "more religious than usual". He seems slightly drowsy and knows the date. His physical examination is normal. The most appropriate next step in management is to order
A. acetaminophen and salicylate levels
B. blood alcohol level
C. ECG
D. urine toxicology for street drugs
E. valproic acid level

The correct answer is C.ECG
This patient may have taken several cardiotoxic medications. Haloperidol and other antipsychotics increase the QT interval, as do the tricyclics. In an overdose for either medication, he is at risk for sudden death from torsades.



A 14 y/o boy is brought to the office by his mother because of "bedwetting" episodes that have been occurring about twice a week for the past few months. The mother says that she noticed this "problem" when she washed his pajamas, and he "refused" to talk about it when she tried to bring it up. She is hoping that he will talk to you. You ask her to leave the room so you can have some privacy with her son. He starts the conversation by stating that "this is getting embarrassing" and he "doesn't understand what's going on." He says that he gets up and finds his pajamas "wet and sticky." He denies any dysuria or frequency during the day, and denies any problems at school or at home. He is on the basketball team, socializes with friends, and gets good grades. Physical examination is unremarkable and shows a pubic hair stage of Tanner IV and genital development Tanner stage III. The next best step is to
A. advise him to stop drinking water at 8 pm and urinate before bed
B. begin a 3-day treatment regimen with trimethoprim-sulfamethoxazole
C. obtain a urine sample for U/A & culture and sensitivity
D. order a renal ultrasound
E. reassure him that this is a completely normal part of puberty
F. order CBC & electrolytes

The correct answer is E. reassure him that this is a completely normal part of puberty
This adolescent boy is most likely having nocturnal emissions ("wet dreams"), which are a normal part of puberty. A nocturnal emission is when the penis becomes erect during sleep and ejaculates. If the boy or his mother do not know about nocturnal emissions before they occur, they may think that he urinated. He should be reassured that this is normal. It is also important to discuss it with his mother so she does not make him feel uncomfortable about it in the future.




A 36 y/o woman comes to the ED because of a severe headache. She states that the headache woke her up from sleep 6 hours ago, and was not relieved by aspirin or acetaminophen. She also noticed that she has neck stiffness and that "it hurts" during neck extension and flexion. She was recently diagnosed with Hodgkin's disease, but before that, she was usually "pretty healthy," except for a few UTI and HTN. V/S: T=39.0 C (102.2 F), BP=130/80 mm Hg, PR=75/min, and RR=17/min. She appears lethargic. P/E shows nuchal rigidity, flank tenderness, and a mid-systolic click. Funduscopic examination shows bilateral optic disc swelling. What’s the most appropriate first step to do:
A. B/C & administer IV ceftriaxone
B. order a CT scan of the head
C. order a MR angiogram of the head
D. order an MRI of the head
E. perform a LP

The correct answer is A. B/C& IV ceftriaxone
This patient has the signs and symptoms that are suggestive of meningitis, but she also has papilledema (optic disc swelling), which means that an intracranial mass must be ruled out before performing a lumbar puncture (to reduce the risk for brain herniation). However, empiric antimicrobial therapy should be started before the neuroimaging study so that clinical deterioration does not occur.



A 17 y/o girl is brought to the office by her mother because she has missed “many periods”. The girl admits to binge eating and exercising in order to prevent weight gain. She tells you that she is definitely not pregnant, because she has not had any sexual relations in the past 11 months and thinks she is not getting her menstrual period because of the excessive physical exercise she has been doing in the past several weeks. P/E is significant for bradycardia and significant weight loss compared to the last year. A pregnancy test is negative.At this time what’s the first step?
A. order amylase
B. check BUN and creatinine
C. order LFT
D. check serum K
E. thyroid function tests

The correct answer is D. check serum K
Bulimic patients frequently engage in compensatory behaviors to prevent weight gain. Those include self-induced vomiting, abuse of diuretics, laxatives, enemas, or diet pills. The metabolic disorders frequently seen in these patients are, mostly hypokalemia and hypomagnesemia. Thyroid function tests should be done as a part of regular workup of patients presenting with this clinical picture. It is not, however, the first to be ordered.



45 y/o truck driver involved in MVA, resulted in closed hesd injury, presents to ER, he was intubated at the field and on arrival he’s oxygenated well with assisted ventilation, has normal BP & moderate tacchycardia. GCS = 7, pupils are equal & slowly reactive. After stabilization, a head CT is done which shows small SAH & Rt. frontal lobe contusion. Abd. CT is normal. The optimal Mx of this px ICP is :
a- fluid restriction, hyperventilation, IV steroids
b- fluid restriction, hyperventilation & ventriculostomy
c- fluid restriction & osmotic diuresis
d- normovolemia, normocarbia & ventriculostomy
e- craniectomy

answer is d- normovulemia, normocarbia & ventriculostomy
The principle of Mx of closed head injury is to maintain cerebral perfusion & oxygenetaion to prevent secondary brain damage. Remember this formula:
CPP ( cerebral perfusion pressure )= mean BP – ICP, So normal CPP requires adequate circulating blood volume with maintanace of normovolemia. Early ventriculostomy is beneficial to permit controlled drainage of CSF to maintain normal CPP.
Note: Fluid restriction, hyperventilation, hypercarbia ( -- > vasodialation & inc. ICP ) should be avoided.



A 70 y/o man with hx of HTN & mild CHF ( which was controlled with digoxin & diuretics ) is admitted for an AAA repair. To faciliate perioperative Mx, a swan- ganz cath. is inserted in the OR. During a first few hours post op he’s noted to have BP= 140/70, HR=110, flat neck veins, pulmonary arterial wedge pressure of 9 mm/hg & poor urine output.
1- The next best step of Mx is :
a- IV furesmide
b- Bolous IV crystalloid
c- Dopamine infusion
d- Nitroprusside infusion
e- IV digoxin

Several hours after this intervention, BP=150/85, HR=90, neck veins are distended, pulmonary arterial wedge pressure is 17 and urine output is still low.
2- At this point, Mx should be:
a- IV furesmide
b- Bolous IV crystalloid
c- Dopamine infusion
d- Nitroprusside infusion
e- IV digoxin

Answers are: 1- b, 2-d
In the initial post op period, px has a low pwp & poor urine output, renal perfusion is compromised by hypovolemia with subsequent inadequate preload & decreased cardiac output. So at this time IV fluid resuscitation is appropriate.
After fluid bolous px developes extended neck veins & elevated pwp, indicating biventricular dysfunction with increased left end diastolic pr. & increased left ventricular end systolic volume. CO is low & urine outpout is not improved, so with px hx all scenario is due to increased afterload which can be reduced by nitroprusside infusion.



70 y/o man presents with back pain & difficulty urination. On DRT, he has a hard, irregularenlarged prostate. PSA is elevated & osteoblastic lesions of vertebral column & pelic bones are noticed. The Tx of choice is:
a- radical prostatectomy
b- transurethral prostatectomy
c- cytotoxic chemotherapy
d- hormonal manipulation
e- radiotherapy

answer is d- hormonal manipulation
this elderly px has metastatic prostate cancer, so Mx would be tumor control for palliation of symptoms, which is hormonal manipulation either with orchiectomy or exogenous estrogen therapy.



A 75 y/o woman is brought to ER from nursing home for jaundice & mental confusion. The nusrsing home notes states that she became less responsive & developed jaundice over the last 2 wks. PMH is positive for HTN, DM & prior colon resection for colon cancer at age 55. V/S : BP= 100/60, HR= 110, T= 101.5, P/E shows no response to verbal command but withdraws to pain, a mild jaundice with tenderness in epigastrium & RUQ. What’s the most likely Dx?
a- Hepatitis A
b- Biliary stricture
c- Choledochal cyst
d- Liver metastasis
e- Choledocholithiasis
f- Cirrhosis
g- Pancreatitis

Answer is e- choledocholithiasis.
Common bile duct stones may be the cause of acute bile duct obstruction without warning resulting in jaundice, pain & sepsis. The sepis may manifest as fever, hypotestion & altered mental status.

A 66 y/o woman who has previously been healthy undergoes emergency surgery for a ruptured AAA. Intraoperatively she requires 8 units of packed red blood cells to maintain her blood pressure and hematocrit. After surgery she is hemodynamically stable. On the third post-op day she appears jaundiced, but abdominal examination is unremarkable and she is afebrile. Lab results:
Total serum BR=8.3 mg/dL (direct= 6.3 mg/dL)
Serum Alk. Ph.= 360 U/L
Serum AST = 51 U/mL
The most likely explanation for the woman's jaundice is
A: a stone in the common bile duct
B: halothane hepatitis
C: posttransfusion hepatitis
D: acute hepatic infarct
E: benign intrahepatic cholestasis

The answer is E- Benign intrahepatic cholestasis
Benign post-op intrahepatic cholestasis can develop as a consequence of major surgery for a catastrophic event in which hypotension, extensive blood loss into tissues, and massive blood replacement are notable. Factors contributing to jaundice include the pigment load from transfusions, decreased liver function resulting from hypotension, and decreased renal bilirubin excretion caused by tubular necrosis. Jaundice becomes evident on the second or third postoperative day, with bilirubin levels (mainly levels of conjugated bilirubin) peaking by the tenth day. Serum Alk. Ph. concentration may be elevated up to tenfold, but AST level is only mildly elevated. Hepatitis, choledocholithiasis, and hepatic infarct are unlikely diagnoses in the absence of abdominal tenderness, fever, or a significant rise in AST levels. The incubation period of posttransfusion hepatitis is 7 weeks, making this diagnosis unlikely.



A 6 y/o boy is brought by his mother because of a "red rash" that she noticed today. She says that 3 days ago he had a cough, runny nose, and fever that responded to ibuprofen. T=37 C (98.6 F) and he has a normal P/E with the exception of an erythematous, blanching macular rash on his legs. You diagnose him with a viral exanthem and advise the mother to encourage the child to drink liquids and to use ibuprofen as needed for fever. One week later, the mother brings the child back to the office and reports that the rash has "changed", he has developed colicky abdominal pain several times per day, and he is complaining of left knee pain. V/S: T=37.2 C (99 F), BP=100/65 mm Hg, PR=100/min, and RR=15/min. P/E reveals a well-appearing child with palpable purpura of both lower extremities, normal neck examination, clear lungs, and a soft, non-tender abdomen. His left knee is painful on flexion, but it is not erythematous or warm, and there does not seem to be an effusion. His gait is normal. The most appropriate study at this time is :
A. arthrocentesis
B. colonoscopy
C. cultures of blood, urine, and cerebrospinal fluid
D. echocardiography
E. urinalysis
The correct answer is E.
This patient most likely has Henoch-Schonlein purpura (HSP), a small-vessel vasculitis seen most commonly in children between the ages of 2 and 8. The child's preceding upper respiratory tract infection, low-grade fever, and arthralgias are all common elements of this disease. The typical rash of HSP is an evanescent, erythematous, macular rash on the lower extremities that progresses over the course of days to petechiae and palpable purpura. These change in color from red to purple to brown before eventually fading, normally over the course of weeks. HSP is an IgA-mediated autoimmune vasculitis, which can cause tissue damage as a result of immune complex formation. Deposition of these immune complexes in the kidneys can lead to nephritis, which is the leading cause of permanent sequelae from HSP. End-stage renal disease is an uncommon but possible outcome. It is important to perform frequent urinalyses for early detection of kidney involvement.



A 5 y/o boy is admitted to the hospital because of his increasing irritability and fever. The mother reports that the child has been having upper respiratory symptoms for the past week. In the last few days, the child has been constantly rubbing his left ear and has been increasingly irritable. The patient has had multiple ear infections in the past, that were treated with oral antibiotics. Following recurrent episodes of these ear infections, the child was advised to take a prophylactic, single dose of amoxicillin at bedtime. The child has been taking these antibiotics regularly for the past 3 months. On examination, the child is found to have a fever of 38.8 C (101.8 F). Examination of the right ear does not reveal any abnormalities. The examination of the left ear is uncomfortable, but the external auditory meatus appears normal. The tympanic membrane is examined after the removal of the cerumen and is noted to be hyperemic, bulging with indistinct anatomical landmarks. Light reflex is diminished and there is limited mobility on pneumatic insufflations. Some amount of middle ear effusion is also noticed. The most appropriate next step in the management is to
A. advise a tympanostomy tube placement
B. continue antibiotic prophylaxis with amoxicillin
C. prescribe a 10-day course of oral antibiotics
D. recommend decongestants, along with oral antibiotics
E. start intravenous antibiotic therapy
The correct answer is A.
Referrals for discussion of a tympanostomy tube placement should be considered if there is chronic bilateral effusion for more than 3 months in duration, unilateral effusion for more than 3 months in duration, language development delay, hearing loss of more than 20 decibels, or failure of antibiotic prophylaxis. This particular child has a history of recurrent acute otitis media treated with antibiotic prophylaxis. Failure of antibiotic prophylaxis requires tympanostomy tube placement.




An 8 mo/o infant is braught because of constipation. The father, a "stay-at-home dad," tells you that she has been having 1 bowel movement every 3-4 days, and that the stool is always very hard. He says that she is doing very well otherwise; she is a very happy and easy little girl. She is fed primarily infant formula and he is starting to introduce solid foods. He says that he is concerned because he remembers always having to change "very dirty" diapers for both of his other children, at least twice a day. Physical examination is unremarkable. A rectal examination shows guaiac negative brown stool. The most appropriate next step is to:
A. advise him to give her mineral oil 3 times a day until she is "regular"
B. advise him to give her prune juice or pear juice
C. determine thyroid-stimulating hormone levels
D. order a barium enema
E. order rectal manometry and a rectal biopsy
F. reassure him that all infants have different bowel habits
The correct answer is B.
Constipation is a common problem in formula-fed infants, and it is best treated by increasing the amount of fluids in the diet, especially with fruit juices that contain sorbitol, such as prune and pear, which help to relieve constipation. It is often caused by a diet that is too low in fluids or deficient of bulk.


A 7 day/o boy who is the product of an uncomplicated gestation is brought to the physician because of hypospadias. The baby is otherwise healthy, and is urinating without any difficulty. On physical examination, vital signs are stable, lungs are clear and the heart is beating at a regular rate. The only abnormal physical finding is the hypospadias. U/A is negative for infection. Which of the following is the most appropriate next step?
A. Measuring serum creatinine level
B. Schedule a renal ultrasound
C. Obtain an IVP
D. Cystography
E. Performing a circumcision

The correct answer is B.
Children with hypospadias are prone to urinary tract infections and other urinary tract anomalies. They require careful evaluation. A renal ultrasound is a safe way of diagnosing neonatal urinary tract pathology.



A 4 y/o old boy falls from the jungle gym at preschool. He sustains minor abrasions and contusions, and is taken care of by the school nurse. His parents take him that same afternoon to his regular pediatrician, P/E is unremarkable, his Hgb=14 g/dL, and U.A shows microhematuria. Which of the following is the most appropriate next step in management?
A. CT scan of the abdomen and pelvis
B. Reassure the parents that microhematuria from minor trauma will resolve spontaneously
C. Serial hemoglobin and hematocrit determinations
D. Urologic workup, starting with a sonogram
E. Retrograde ureterogram and cystogram

Answer is D.
Microhematuria after trivial trauma in children may be a sign of a congenital anomaly that makes the urinary tract unusually vulnerable. So work up is necessary. The first, noninvasive test should be the sonogram.



A 5 wk/o infant is brought for a 4 wk hx of noisy breathing that has not improved. She has otherwise been healthy except for a current URI for the past 4 days, which according to the parents, has worsened the noisy breathing. On P/E, she has inspiratory stridor. The noisy breathing improves when the infant is asleep. Which of the following is the most likely diagnosis?
A. Bronchoalveolar carcinoma
B. Foreign object obstruction
C. Laryngomalacia
D. Bacterial pneumonia
E. Tuberculosis

The correct answer is C.
The patient has stridor on examination which is an inspiratory obstruction that is sensitive to airflow changes. In children, the most common cause of stridor is laryngomalacia.


A 5 y/o boy develops a headache, cough, myalgia and a fever. He has been a healthy child with all immunizations up to date. He is given a decongestant and an aspirin for his symptoms with some relief. However, 4 days later, he is brought back by his parents because of persistent vomiting and irritability. On P/E, he is found to be semicomatose, becoming combative on stimulation. Which of the following would confirm the Dx?
A. Serum ammonia
B. Serum BUN
C. Serum calcium
D. Serum opiate level
E. Serum Na

The correct answer is A.
The child is presenting with symptoms of Reye syndrome, which is an acute encephalopathy associated with high ammonia levels. It most commonly occurs in young children after a viral illness. Administration of aspirin increases the risk of developing this disorder. The vomiting is characteristic.


A 3 wk/o African American boy is presented because of a generalized seizure 2 hrs ago. The infant is highly irritable with high pitched cry, his weight is 2.5 kg, BP=70 /40 mm Hg, PR=145/min and RR=50/min. Laboratory results:
Blood Glc=120 mg/dL
BUN= 50 mg/dL
Serum Na=170 mEq/L
Serum Ca=8.5 mg/dL
Serum magnesium=1.5 mg/dL
Which of the following is the most likely cause of this infants seizure?
A. Hypocalcemia
B. Hypoglycemia
C. Hypomagnesemia
D. Intracranial hemorrhage
E. Meningitis

Answer is D- intracranial hemorrhage
The level of serum sodium in this patient is 170 mEq/L. Infants who have hypernatremic dehydration are irritable and lethargic, and have a high-pitched cry. This type of dehydration results from a greater loss of hypotonic fluid than sodium and accounts for about 15% cases of dehydration. Because the patient has no history of diarrhea or vomiting, the hypernatremia may be due to inadequate supply of mother's milk that does not match the insensible water loss. Another cause can be the high concentration of sodium in mothers milk. Generally, after the child's birth, sodium in the colostrum decreases from its highest level to its lowest level by the fourth week. However, some mothers continue to excrete high sodium in their milk and can potentially cause recurrent hypernatremia and in some case intracranial hemorrhage in the infant.



3 y/o child presents with recurrent Rt. lower lobe pneumonia. Growth parameters is on 25th percentile & developmentally appropriate for his age. PMH is significant for ear infection at 18 months & gastroenteritis at 2 yrs of age. Which of the following conditions is most likely responsible for this pt.'s disease?
1.Primary B- or T- cell immunodeficiency
2.Cystic fibrosis
3.Chediak higashi syn.
4.Congenital lung abnormality
5.Foreign body aspiration

Answer is 5. foreign body aspiration
Foreign body aspiration is the most common cause of recurrent pneumonia in an otherwise healthy 3 yo child. Becoz of the lung's anatomy,the rt.side is more common for aspiration.


A 4 mo/o white male is braught for his well-child visit. Both his father and his teenage brother have idiopathic epilepsy, which began during early childhood. Six hrs after the infant's 2-month DTaP he developed a fever of 39.5° C (103.1° F) rectally. His parents are concerned about the safety of further DTP immunization. Which one of the following is the best approach to DTaP immunization at this visit?

a. Administer the routine DTaP immunization
b. Administer DTaP (acellular pertussis)
c. Administer one-half the usual dose of DTaP
d. Administer dT (no pertussis component)
e. Delay further DTaP until he is 6 months old

Answer is a.
False assumptions regarding contraindications often result in the needless deferment of indicated immunizations. The list of contraindications and precautions for DTaP immunization does not include a previous febrile reaction unless the fever was greater than 105° F, nor does it include a family history of seizures.


1- 32 y/o man presents with dizziness and syncope when elevates his right arm. Subclavian steal syn.
2- 70 y/o man with back pain, increased urinary hydroxyproline and serum alkaline phosphatase. Paget’s dis. of the bone
3- 28 y/o woman complains of tremors, nervousness, and weight loss, ECG shows atrial fibrillation. Hyperthyroidism
4- 62 y/o man with gastric cancer presents with velvety brown thickened skin of the body folds. Acanthosis nigricans
5- 9 y/o boy presents with pain in the medial side of the foot, X-ray shows a narrow scaphoid. Kohler’s dis.
6- 5 y/o child presents with a painful rib swelling, X-ray shows a rounded osteolytic lesion. Eosinophilic granuloma
7- 62 y/o man had few episodes of complete blindness in one eye which lasted for 30 seconds each. TIA
8- 50 y/o man with intermittent claudication, impotence, and pain in the buttocks. LeRiche syn.
9- 2 y/o child is brought to you with a thin-walled cyst in the supraclavicular area. Cystic hygroma
10- 6 months after cardiac surgery, a 58 year old man develops fever, pericarditis, and an elevated ESR. Dressler’s syn.
11- 8 y/o girl is brought to you with fever, cervical adenopathy, conjunctivitis, and a scarlatiniform rash on the upper chest. Kawasaki dis.
12- 32 y/o woman presents with severe right lower quadrant pain and a palpable adnexal mass, she has no fever and her hCG is negative. Ovarian cyst torsion
13- 24 y/o woman develops erythematous skin eruption following a week's course of antibiotic therapy for UTI. Erythema multiform
14- 62 y/o woman complains of jaw pain when chewing and diminished vision of her right eye. Temporal arteritis
15- 52 y/o man presents with severe midchest pain followed by bouts of vomiting, chest X-ray shows pneumomediastinum. Esophageal rupture
16- 73 y/o woman presents with sticky, yellowish vaginal discharge, the vaginal mucosa is thin and pale. Atrophic vaginitis
17- 9 y/o boy presents with recurrent episodes of abdominal pain and painful swelling in the hands. Hereditary angioedema
18- 62 y/o woman presents with severe joint disease, hepatosplenomegaly, and leg ulcers. Felty’s syn.
19- 38 y/o man complains of severe headaches and blurred vision, his jaw is protruding and his tongue is enlarged. Acromegaly
20- 62 y/o man presents with a severe, slowly progressive abdominal pain, followed by a bloody diarrhea. Intestinal infarction
21- 45 y/o diabetic woman presents with numbness over the palmar side of the thumb, the index and middle fingers. Carpal tunnel syn.
22- 46 y/o man develops paralysis of the proximal and distal muscles of the leg after recovering from pneumonia. Guillain barre syn.
 
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* Re:lots of questions from classified section of th
#716273
  superdoc2008 - 03/23/07 00:18
 
  U r doing a gr8 jpob dude  
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* Re:lots of questions from classified section of th
#716369
  anothergoljafan - 03/23/07 04:26
 
  thanks man.  
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* Re:lots of questions from classified section of th
#716370
  anothergoljafan - 03/23/07 04:26
 
  1. propranolol=drug of choice for HTN+beningn essential tremor


2. )Reccurent chalazion=> do histopathologic examination because of risk of Squamous cellular carcinoma (SCC)


3. )PH=7.23, HCO3=16, PCO2=40-what is it?
=mixed metabolic+respiratory acidosis, because if it were simple metabolic acidosis, then PCO2 would have been=1.5*HCO3+8=1.5*16+8=32mmHg and in this case it is 40mmHg, so there is also a respiratory acidosis


4. Know the formula for calculating the compensation in acidosis: PC02=1.5*HCO3+8
Ex.: a diabetic suffering from COPD treated with metformin may have mixed acidosis, metabolic from metformin, respiratory from COPD.


5. )NSAID can give SIADH (innapropriate secreation of ADH)


6. )Quinsy=peritonssilar abcess


7. )Tamsulosin=blocks alpha1-receptors only in prostate and bladder=>no side effects like hypoTN, headache, rhinitis as other alpha 1 blockers


8. )Sideroblastic anemia-high Fe, high TIBS, may be hypocromic and normocromic anemia in the same time=HIGH YIELD


9. )Streptoccocus bovis endocarditis-asoc. with colorectal cancer=>do colonoscopy


10. )Treatment of MG crisis=intubation+withdrawl of anticholinesterasic drugs for many days, then do plasmapheresis and iv IG


11. )Foreign body in the eye=>first pen light exam=>fluoresceine exam, if still (-)=>CT or US, never MRI (it can dislocate the foreign body)


12. )patient with XYY karyotype=severe acne, but not precocious puberty
21-hydroxylase deficiency=precocious pseudo-puberty, independent of the hypotalamic-hypophyseal-gonadal axe


13. )Black widow spider bite=>treat with narcotics, muscle relaxants and Ca gluconate


14. )Women with CIN (cervical intraepithelial neoplasia):
a) imunocpmpromized
b) in utero exposure to DES
c) hystory of CIN II/III
will have annual PAP smear done, regardless the normal previous ones.


15. )In severly depressed patient, even suffering from terminal illness with suicidal thoughts=>start antidepressant therapy


16. )Systemic steroids=drug of choice in sarcoidosis with disabling symptoms, if not responding=>cyclosporine
if asymptomatic sarcoidosis=>no treatment


17. )Lachman test is more sensitive than anterior drawer test in ACL rupture (anterior cruciate ligament)


18. )Primary polydipsia=increased thrist first, can be given by antipsyhotic medication


19. (phenotiazines) because they give a dry mouth. Look for a patient in the psychiatric ward on antipsychotics who gets diarhhea, polyuria and thrist
Insipid diabetes=increased polyuria first


20. )HTN+peripheral vascular disease=>give Ca channel blocker


21. )BCC (basal cell carcinoma)=most common tumor of the eyelid
=pearly, indurated
=>treat by chemosurgery of frozen section control excision


22. )Respiratory alkalosis-in liver insufficiency because of increased levels of progesterone (not metabolized anymore)


23. )Hashimoto thyroiditis-can be eu/hypo/hyper thyroid
-anti preoxidase Antibodies are diagnostic
-risk (6 times) of thyroid lymphoma

24. )Nasopharingeal carcinoma-appears in all age groups


25. )Colonic villous adenoma, sessile adenoma or size>2.5 cm=> increased risk of malignancy=HIGH YIELD
No further work-up for hyperplastic polyps


26. )US of KUB (kidney, ureter, bladder)=first step in evaluating BPH (benign proastate hypertrophy) with elevated Creatinine and normal urinalysis


27. )MALT gastric lymphoma and no metastasis=>eradicate H.pylori infection, if this fails, then give chemotherapy (CHOP)


28. )Athlete's foot (in swimmers too)=fungal infection, treat with tolnaftate


29. )Excessive bleeding (like abruptio placenta) in pregnant woman Rh (-)=>give higher dose of anti-D globulin


30. )If HDL>60mg%=>it removes one risk factor for CV disease


31. )Alcohol withdrawl=>first-line give chlordiazepoxide (librium), then lorazepam=second-line


32. )Sjogen syndrome=>diagnosis confirmed by lip biopsy (lymphoid foci in accessory salivary glands)=most specific


33. )Allergic contact dermatitis=erythema, edema, pruritus, tiny vesicles, weepy&crusted lesions 24-48h after contact with the allergen-cell mediated hypersensitivity


34. )Psammoma bodies=thyroid papillary cancer
Invasion of tumor capsule and blood vessels=folicular cancer
Hurtle cells-appears in both the above types (rarely)

35.
)Carcinoid syndrome=>develop deficiency of niacine (dermatitis, diarhea dementia) because Trp is mainly converted to serotonine and 5HIAA
Hyper Ca crisis=vomiting, oliguria/anuria, dizziness, coma


36. )Invasive aspergillosis="halo sign" on CT scan of lung
=in imunocompromized people
=on CXR-cavitary nodule


37. )Miastenia gravis=>thymectomy if:
-between age of puberty and 60
-if <12 years of age=>frecquent spontaneous remissions
-if>60 years of age=>give corticosteroids
-if only ocular disease=>no thymectomy


38. )Defect in Le adhesion=reccurent bacterial infections
-characteristic are: delayed separation of umbilical stump
necrotic periodontal infections


39. )Defect in opsonisation=asplenia (infections with S. Pneumoniae are frecq)


40. )Acute ingestion of masssive alcohol=> reduces the toxic effect of acetaminophen by inhibiting CYP2E1 like in suicide attemps with alcohol and acetaminophen together, but
Chronic ingestion of alcohol reduces glutathion=>increases the toxicity of acetaminophen like in an alcoholic patient with some kind of fever due to common cold


41. )Egg allergy=>contraindication to influenza vaccine and Q fever vaccine, and relative c.i. to MMR (which is however still recommended)-HIGH YIELD


42. )ACE inhibitors=>increase renin and kinin derivates=>cough


43. )Dermatomiositis=Gottron's sign=scaly patches on MCP and IP joints
=heliotrop rash (periorbital edema+purplish suffusion)
=proximal muscle weakness

44. )Vertebral osteomyelitis-lumber area frecq.=>back pain
- low fever, high ESR, local tenderness, spasm
Do MRI=of choice for diagnosis
-Complications=epidural abcess, spinal cord compression

45. )Pale lesions, velvet-pink or whitish that do not tan and are not scaly=tinea versicolor (Malassezia furfur)
-thick budding spores, large blunt hyphae="spaghetti and meatballs"
-treat=>Se sulfid shampoo and ketoconazole


46. )Loss of gastric fluid by NG suction in intestinal obstruction=>metabolic alkalosis (contraction alkalosis) even if initially it was a metabolic acidosis from the obstruction

47. )Hypophosphatemic rickets-only P is low, the rest are normal (PTH, Ca)

48. )Migratory trombophlebitis-due to cancer=> do CT of chest abdomen and pelvis; can be pancreatic, lung, prostate, stomach cancer


49. )Acyclovir=nephrotoxic=>renal tubular obstruction, gives crystalluria
)Deficiency of Iron=most common anemia in the elderly=HIGH YIELD
)Anemia of chronic disease is given by inflamatory joint disease not degenerative joint disease

)Pseudomonas osteomyelitis (punctures through snikers in the foot)=>give quinolones+surgical debridement
) Anemia of prematurity-normocitic, normochromic, low reticulocytes, few precursors of red line, normal WBC, T, normal Bilirubin, , no other abnormalities

)Isoniazide=>lowers the levels of GABA in the brain=>seizures in 1h after administration, treat by Vit. B6
)For screening use=total cholesterole+HDL
For treament use=LDL+Risk assessment

)Undiagnosed pleural effusion=best evaluated by thoracocentesis, except in CHF (here give diretics and see what happens-it will disappear)-HIGH YIELD
Varicose veins with incompetent perforating veins- can give:
-non-pitting edema
-medial leg ulcer
-fatigue
-brown discoloration of the ankles

)Warfarin induces skin necrosis=>mostly in patients with deficiencies of prot C or S or when it is started in high doses without prior heparin coverage (like in Atrial fibrillation)

)Larger Confidence interval (CI)=wider range of possible effects for a tested drug (efficient drug in some patients, non efficient in others)
If CI of 2 groups overlap=>no statistical significance
If they don't overlap=> statistical significant differences

)Niacine treatment=> raises HDL, but gives pruritus and flushing (release of Prostaglandines)=>prevent this by giving aspirin 30 min. prior to taking niacine

)Pulmonary embolism (PE)-post surgery in pacients with JVD and new RBBB; also dilated pupils=ominous sign

)Post-ictal (after seizures) lactic acidosis is transient=> no treatment, it resolves by itself in 60-90 min.
HCO3 is given in acidosis only if PH<7.2

)In primary hyper aldosteronism, there's no edema, but hyper Na

)Retinal vein occlusion=disk swelling, venous dilation and tortuosity, retinal hemorrhages, cottol-wool spots
)Retinal artery occlusion=pale disk, cherry-red fovea, boxcar segmentation of blood in the retinal veins

)Celiac disease-diarrhea, pallor (anemia), bone pain (osteomalacia), easy buising (low vit.K), hyperkeratosis (low vit. A), Ig A Antib. to gliadine, to endomissium and to tissue transglutaminase
=malabsortion+Iron def. anemia

)Overflow incontinence-can be given by: TCA, antichol., antipsychotics, sedative-hypnotics

)Spinal cord compression=>first give STEROIDS, then do MRI of the spine, if not available do=>CT myelogram=> give radiotherapy for malignancies=HIGH YIELD

) Diagnosis of Bartonella Henselae is clinical, confirm by Warthin-Starry stain of tissue specimen or Antib.
treat by azytromycin for 5 days and only in regional lymphadenopathy or systemic symptoms (also can give claritromycin, rifampin, TMP/SMX, cipro or Doxi)

)Shy-Dragger syndrome=Parkinson +autonomic instability (HypoTN...)
-can have bulbar dysfunction or laringeal stridor
-treat by iv expansion (fludrocortisone), salt, alpha agonists
Riley-Day Syndrome-AR disease, in Askenazi Jews
=autonomic dysfunction +severe hypoTN

)Prepubertal vulvo-vaginitis=>pruritus mainly in the night=>do scotch tape test to detect pinworm (do not answer stool examination)
)Treatment for low HDL=>Choice=fibrates, the niacine
)Treatment of choice for anorexia=hospitalisation

)Subcutaneous emphysema in patients on 100% O2 on mask=> do first CXR to rule out pneumotorax; if (-) this is a benign condition=>no furthet treatment

)Thoracic outlet syndrome-after MVA, playing with musicalinstruments, chronic illnesses, cervical ribs, congenital muscle band...=has signs of neuro-muscular bundle compression
-do EAST test for screening (elevated arm stress test), and CXR, MRI or angiography for confirming the diagnosis

)Medial meniscus tear-C shaped meniscus (the lateral is O-shaped)
by twisting the leg, effusion forms in 24h and is not as bloody as in ACL tear, tenderness on the medial part on the knee
=characteristic=bucket handle tear and locking of the knee joint in extension
(+)McMurray sigh=snapping felt with tibial torsion, knee flexed at 90 degrees
-trea by immobilization+bracing

ACL tear=hystory of hyperextension
(+) Lachman test, ant. drawer test, pivot shift test

)CI=1.02-2.15
RR=1.6 What does it mean? Well, the CI does not include value of where RR=1, then it means that the result is statistical significant
RR=1=> no effect or association

)Low cardiac output + high PCWP+high SVR=left ventricular failure (cardiogenic shock)=HIGH YIELD, I got some similar questions on actual exam, know this type of Q for cardilogy very well!!!

)Eczema herpeticum=HSV infection associated with atopic dermatitis, there are vesicles over the areas of atopic dermatitis
treat by acyclovir in infants

)Causes of altered mental status in the elderly patients:
low+high Na, Ca, low Mg, low P, low glucose, stroke, cardaic events, infections
-risk of dehydration by:WATER ACCESS IS DENIED=main mechanism in:
a)nursing homes
b)post-surgery
c)intubation in ICU

)To slow down the progression of Diabetic nephropathy=>restrict proteins and give ACE inhibitors (even if normal TN, but not if Clearance of Creatinine>2)

) Treat of both acute and chronic anal fissures=> starts with dietary modifications+stool softner+local anesthetics; in refractory cases do lateral sphincterotomy or gradual dilatation=>risk of incontinence and disruption of sphincter

)Paroxismal nocturnal hemoglobinuria-may cause pancitopenia
-like hemolytic anemia (High reticulocytes)
-intravascular process (high LDH, total billirubin, low haptoglobin)
-splenomegaly, Cooms (-)
-loss of iron in the urine=>microcytes, hyprocromia
-bone marrow=hypocellular
-flow cytometry=absence of CD59 -used for confirmation of disease

)Screen for hepatitis C if blood transfusion was before 1992 and for hep. B is before 1986

)To supress lactation=>tight-feeting bra+ice packs, no longer bromcriptine

)First step in organo-phosphoric poisoning=remove clothes and wash patient, then atropine
)Use CA-125+vaginal US for screening the intermediate risk of ovarian cancer in women with family hystory of ovarian cancer (not other type of cancer); otherwise, there's no screening done for ovarian cancer

)Avascular hip necrosis-given by steroids, scikle cell disease, alcoholism, SLE, Gaucher's disease
=hip pain with normal range of motion and normal X-rays. Do MRI=GOLD STANDARD for diagnosis
)Intraperitoneal rupture of bladder in MVA=previous full baldder in a patient who drank water (2l) and didn't urinated for 8h
Extraperitoneal rupture=more common

)Treat Ig A deficeincy:-prophilactic TMP/SMX, donor erytrocytes washed five times or bloodfrom other IgA def.patients

)HTA+osteoporosis=first choice are THIAZIDIC DIURETICS

)Vitiligo=pale macules with pigmented borders-acral or peri-orificial areas, autoimmune distrcution of melanocytes
Piebaldism=absence pf melanocyes, obvious from birth
Infection with M. Leprae=areas of hypopigmentation+anesthesia

)Metabolic alkalosis:
a) Cl sensitive (Urinary Cl<20mEq/l)-causes;vomiting,diurectics...=ECF contraction; treatable by NaCl infusion
b) Cl resistant (U Cl>20mEq/l)=ECF expansion, not correctede by Na Cl infusion; causes:persistent mineralocorticoid stimulation

)Nerve IX neuralgia-associated with Multiple Sclerosis (MS)

)Nephrotic syndrome-associated with arterial+venous thrombosis (freq. renal vein thrombosis and even PE
-anemia microcytes, hypocromia, resistant to iron therapy (loss of transferine)
-vit D deficiency, low Thyroxine levels

)Angiofibroma in the nose-can give bony erosions
Chondroma of nasal cartillage-is very rare in young patients

)Lyme disease in pregnancy and in children<9 years of age=>give AMOXI, not Doxi; also can give Azytromycin or cefuroxime

)Sympathetic ophtalmia-ant. uveitis, panuveitis, papillary edema, blindness
-by uncovering of "hidden antigens" (auto-Antib, cell-mediated reaction)

)Diphenilhydramine toxicity-seizures+cholinergic effects
Mercury overdose=vomitting, abdom. pains, bloddy diarrhea, renal insufficiency

)Best prevention of osteoporosis=HRT, c.i. if hystory of endometrial/breast cancer, but not if only family hystory

)Pulmonary nodule with cartillage in it=hamartoma=>observe
Radiotherapy-use it emergently in Superior Cava Vein syndrome

)Dupuytren contracture-associated with alcoholism, epilepsy, DM, TB, Peyronnie disease, Riedel thyroiditis; over 50 years of age

)Perforated retro-cecal appendix, edematous cecum, pus behind the ascending colon=>do right hemicolectomy+ileo-transverse anastomosis=best post-surgical results

)Excruciating pain from femur fracture=>give iv. Morphine (even in patients with hystory of drug abuse), then give PCA (patient controlled analgezia)
Give methadone in chronic severe pain syndromes

) If a test is (-)=> probability of the disease is =1-NPV

)HCO3 if given in lactic acidosis can depress the myocardium and increase the production of lactic acid by stimulating the phosphofructokinase enzyme

)Most common location of ischemic colitis is splenic flexure, than recto-sigmoid area

)MCC of bleeding in patients with renal failure is platelet dysfunction; treat by DDAVP

)Bacterial meningitis-treat empirically with ceftriaxone+vancomycine
Give iv dexamethasone in intracranial HTN and bacterial meningitis in infants

)The decision of using N-acetyl-cysteine for acetaminophen overdose is based on the drug levels taken at 4h post-ingestion. But if taken>7.5g acetaminophen or levels are not available at 8h of ingestion=>start treatment

)COPD exacerbation with: ph=7.32, pco2=52, po2=60=> give NIPPV (non-invasive positive pressure ventilation)-the indications are:
ph<7.35
pc02>45mmHg
Resp. rate>25/min.

)Adult Still's disease-variant of RA
-at 20-30 years of age
-high spiking fever
-salmon colored rash along with thye fever
-arthralgias, lymphadenopathy, high Le

)Any gunshot under the 4th i.c. space=>do laparotomy of the abdomen

)Latex allergy-associated with spina bifida
-gives anaphilactic reaction to "sex and surgery" (because of condoms and surgical gloves)

)Selection bias=loss of follow-up in a prospective study

)Reccurent myocardial infarction-detect by serial CK-MB levels

)RTA 1-assoc. with Sjogren syndrome
-urine ph>5.5
low HCO3
low K+

RTA 2-osteomalacia
-urinary ph<5.5
low HCO3 levels
-low K+

)Corrected Ca=measured Ca+0.8 (4.5-measured albumin)
For each 1g of lost albumin, Ca goes down by 0.8-1mg%

)Cavernous sinus thrombosis-like orbital cellulitis but with cranial nerves involvement (III,IV,V, VI) and bilateral
-treat by Antibiotics, then anticoagulation and corticosteroids

)Acute pancreatitis and non-alcoholic=>suspect gall-stones=>do US=first step; do CT only if Le>20000/ml and suspect necrotising pancreatitis

)DM foot ulcer-treat by cephalosporine, ampi/sulbactam, clidamycine+fluoroquinolone

)Syringomyelia=areflexic weakness + dissociated anesthesia in a "cape" distribution in the upper extremities

)Emergent contraception=estradiol+norgestrol, 2 tb taken in no later than 72h, 12h apart

)HIV individuals-give Td vaccine

)Aspirin sensitivity syndrome=pseudo-allergic reaction; treat with leukotriene inhibitors=drug of choice

)To confirm Ankilosing spondilitis=>do X-ray of the sacro-iliac joint, if not conclusive=>do CT
)Splenic rupture- the need of surgery determined by:
a)vital sighns+hemodynamic stability
b)change in hematocrit over time
c)need for blood transfusion

)NTG-dilates the capacity vessels not the resistance vessels=>reduces preload


)Molluscum contagiosum-poxvirus
-diseminated in HIV patients
-central umbilicated, dome shaped
resolves spontaneous in 1 year

)Bullous myringitis-painful vesicles on the timpanic membrane
-mycoplasma or viral infection

)Drug-induced pancreatitis: valproic acid, diuretics (loop and thiazidic), 5-ASA, sulfasalazine, imunosuppressive (L-asparaginase, azathioprine), AIDS-patient (didanosine, pentamidine), metronidazole, tetracycline

)Cystinuria-reccurent stones since childhood
-family hystory
-hexagonal crystals, hard stones which are radio-opaque
-screening test=urinary cyanide nitroprusside test

)Antiphospholipid syndrome-reccurent fetal losses, reccurent artery+vein thrombosis
-types-I has false (+) VDRL
-II has lupic anticoagulant=>false + APTT
-III-has anticardiolipin antibody
treat in pregnancy by: heparin+aspirin and measure factor X activity and not APTT for treatment

)Gilbert syndrome-associated with fasting, alcohol, stress, complete reversal with phenobarbital
Crygler Naijar 1-billirubin=8-30mg%, kernicterus, no response to phenobarbital
Crygler Naijar 2-billirubin<20mg%, no kernicterus, 25% response to phenobarbital

)In gonochoccal arthritis=>do urethral culture to identify the gonococcus

)Common variable imunodeficiency=15-35 years of age
-normal B and T cells
-frecq. sino-pulmonary infections
-low IgG, Ig M, Ig A
Wiskot-Aldrigh=has low IgM, but high Ig A, IgE

)Acute appendicitis-can perforate and give pelvic abcess with diarrhea, fever, tender mass on rectal exam, low abdom pain and not the usual sighns of appendicitis

)PTCA=has better outocme than thrombolysis

)NPV is high and PPV is low if the pre-test probability of the disease is low

)Microalbuminuria in DM=>start ACE inihibitors even if no HTN

)Motility disorder of the oesophagus=>do contrast study=>then oesophagoscopy to exclude mecanic causes (strictures,cancer)=>only then manometry

)Chronic headaches+painless hematuria=>think analgesic nephropathy due to papillary necrosis

)Terminal patients with severe pain=>give short-acting morphine, then long-acting narcotics

)Campylobacter jejuni-MCC of diarrhea
-in undercooked poultry
-diarrhea is watery or hemorrhagic

)Craniopharingiomas-bimodal distribution:
-children (gives growth problems)
-55-65 age group (gives sexual dysfunction, bitemporal hemianopsia-think of a truck driver who has to turn his head all over when looking sideways

)Chlamydia screening-do it in all women under 25 years of age if sexually active

)Nonseminomatous tumor-may give ant.mediastinal mass, high AFP, HCG; treat by cysplatinum for 6 weeks; use the above two markers to monitor the therapy

)Signs of high ICP: dilated pupils, anisocoria
flaccidity, decerebrate or decorticate posturing
papilledema
NOT Glasgow coma scale=it assesses the severity of head injury only

)Matching=tool that makes cases and controls have similar distribution of some important confounding variables; it's an efficient mean to control confounding

)Warfarin induced skin necrosis-pain, bullae, skin necrosis; use heparin until they heal

)Furosemid-is ototoxic

)SLE-has-low T supressor cells, high T helper cells>B-cell hyperactivity>high serum Antib and Ig G auto-anitbodies which form the immune complexes

)Hyperlipidemia 1 and 5=associated with pancreatitis

)In PCP in HIV patients give steroids, besides TMP/SMX if:
-Pa O2<70mmHg
-A-a gradient>35=150-(1.25*PCO2)-PO2
sat O2<75%

)Amantadine-dual drug=anti-viral+anti-Parkinson

)Granulosa cell tumors-precocious puberty
-postmenopausal bleeding

)Trachoma-given by chlamydia trachomatis (A-C)
-cause of blindness by neovascularisation=pannus
-follicular conjunctivitis
-treat by oral erytro or tetracycline

)Anserine bursitis-medial knww pain below the joint line, hystory of trauma
-valgus stess test is (-), it's (+) in medial collateral ligament strain
-X-ray of tibia is normal

Patellofemural syndrome-in females <45 years
-ant. knee pain aggravated by flexion
-retropatellar tenderness and crepitation

)A narrower CI=>the study is more precise

)If DM type II is not controlled by one hypoglicemic agent, add another one from another class; give insulin only if BUN and Cr are abnormal

)In acute bacterial prostatitis=>get urnie sample for culture before starting empirical antibiotics

)Acute variceal bleeding-give octreotid; beta-blockers are for prophylaxis

)Mucormicosis-treat by surgical debridement and amphotericin B

)Labetalol=drug of choice in pregnancy if HTN+DM nephropathy

)Open-angle gluacoma-cupping of optic disk
-loss of peripheral vision=tunnel vision
-more frecq. in African-Americans
Macular degeneration=central vision loss

)Give MMR to all HIV patients (except those severly compromized)

)Patients with impaired consciousness, advanced dementia=>predisposed to aspiration pnemonia due to impaired epiglotic function


)In patients with frecq. attacks of gout=>first step is to measure 24h urinary uric acid level
-<800mg/day=>under-secretion (probenecid)
->800mg/day=>over-production (allopurinol)

)Ulnar nerve syndrome=MC site of entrapment is: medial epicondilar groove; think of counter clerks who sit with their elbows on the table all day

)In CHF-improved survival by: aspirin, beta-blockers, ACE inhib., spironolactone
-don't improve survibal: digoxin and loop diuretics

)What acid-base disorder is this?
ph=7.53
pco2=30mmHg
HCO3=24
Cl=85
Na=138
Well, tough one: we have alkalosis and is respiratory because Pco2 is low;
AG=Na-(Cl+HCO3)=29=>metabolic acidosis;
But a change in the AG (increase) is accompanied by a similar change in the levels of HCO3 (decrease). Here HCO3 is normal=> metabolic alkalosis.
Scenario (all three together): pneumonia=>respiratory alkalosis
vomiting=>metabolic alkalosis
DKA (from ketones)=>metabolic acidosis

)Any patient with bone pains, renal failure and hypercalcemia has Multiple Mieloma until proven otherwise

)Sudden RUQ pain+rise in hematocrit levels with hepatomegaly, splenomegaly and ascites=>think Budd-Chiari syndrome (from polycitemia vera)=>first step=hepatic venogram or liver biopsy

)Carotid stenosis of >60%-99%=> do CEA even if asymptomatic; complete occlusion=c.i. to surgery

)Lichenus sclerosis-dryness, severe itch, vaginal soreness
-may give vaginal cancer
-do biopsy to rule out cancer
-treat by topical steroids

)Retinal artery occlusion-treat with occular massage+high flow O2
-give thrombolytics within 4-6 hours of visual loss

)TCA- cardiotoxic potential=>because they inhibit fast Na channels
-to asses the severity of the toxicity=>get QRS duration

)Pneumovax-has capsular polysacharrides and gives T-cell independent B cell response; live vaccines give T-cell dependent......

)All uncouncious patients, even those breathing need airway established by:
-intubation in the ICU
-cricothyroidectomy in the field

)In unstable angina=> no thrombolytics; give aspirin, heparin, NTG, beta-blockers

)In MI, give thrombolytics after sublingual NTG to rule out vasospasm.

)VF=is a reentrant ventricular arrythmia

)Superficial spreading melanoma=MC
-increased intraepithelial atypical melanocytes
Acral lentiginous melanoma-on palms, soles, beneath nail plate
Lentigo melanoma-head, neck, arms of fair skinned older people

)Diuretic use (also thiazidic)=>gives metabolic alkalosis

)Euthyroid sick syndrome: low T3, Normal T4, normal TSH; in severe disease: low T4+T3, normal TSH


)Cholesterol embolism-follows surgical or intervention on arterial tree
-livedo reticularis, gangrene, ulcer or mottling of toes
-systemic eosinophilia, low complement levels
-renal failure (eosinophiluria)

)If an ulcer is seen on colonoscopy=>do biopsy to rule out cancer

)Subconjunctival hemorrhage-benign condition, observe only; think of a person with a red eye on awakening in the morning

)Parvovirus infection=>arthralgias of small joints with 5-10 min morning stiffness, normal ESR, no signs of inflamation locally
-joint involvement is symmetrical+-rash

)Intermitent claudication-give aspirin and exercise program
-do angiogram only pre-op,otherwise do duplex arterial study if you want imaging

)Acantosis nigricans-insulin resistance (DM)-in young people
-gastro-intestinal malignancy in the older
-symmetrical, hyperpigmented, velvety palques in axilla, groin, neck

)Drug-induced acute allergic interstitial nephropathy:
a)antibiotics (meticilline, cephalosporine, sulfonamides...)
b)NSAID
c)thiazides
d)phenytoin
e)allopurinol

)Epiglotitis-given MC by H.influenzae type B and strep. group A

)Food droolong out of the mouth and nose during meals=Zenker diverticulum=> can give aspiration pneumonia
-diagnose by oesopphagography

)Chronic diarrhea=>oxalate stones (due to malabs. of fatty acids, they bind Ca and oxalate is free for absortion)

)Gardner syndrome:colonic polyps+lipoma, nasal angiofibroma, gastric polyps, osteomas, epidermoid cysts, more teeth

)Amebic hepatic abcess-"anchovy paste" in the liver
-treat by oral metronidazole (not percutaneous drainage)
-in the tropics acquired

)Cluster headache=>treat by 100%O2 and s.c. sumatriptan; prophilaxis: verapamil, Li, ergotamine

)Vaginal delivery in breech:
-frank or complete breech
->36 weeks of gestation
-weight:2500-3800g
-adequate maternal pelvis
External cephalic version-converts breech into cephalic presentation=>use over 37 weeks until the onset of labor
Internal podalic version-in twin delivery (from transverse/oblique to breech)

)Friedrich ataxia-ataxia, dysarthria, skeletal deformities (scoliosis, hammer toes, pes cavus), cardiomyopathy; three words: neurologic, cardiac and skeletal problems

)Pseudogout-can be triggered by surgery or trauma
-may have 100000 Le/ml in joint fluid

)Nosocomial infections-UTI
-surgical wound infection
-pneumonia

)Know the X-ray appearance of descented aorta aneurysm-well circumscribed lesion=>due to aterosclerosis

)For acute aortic dissection=>use first TEE or CT(only if hemodynamically stable)

)Herpetic withlow-HSV 1 and 2
-in health care workers
-pain in the finger pulp with vesicles and systemic symptoms
-treat by acyclovir+topical bacitracin (to prevent secondary infection)
Felon-appears in tailors
-from needle injuries
-it's a bacterial abcess (tense abcess)=>do drainage+cephalosporine

)Urinary diversion procedure (ureter implanted in the ileum for example)=>gives Hyper Cl metabolic acidosis because the colon absorbs NH4+ derived from ureea under the action of intestinal bacteria
-also the pum Cl/HCO3 functions like this: absorbs Cl, lets HCO3 go!

)Tinitus-by aspirin, quinine
-also in Meniere disease, acoustic neuroma and ...depressed patients=>give TCA

)Chronic myelogenous leukemia=>give IMATINIB (Gleevec)=Tyrosine kinase inhibitor; side effects are: nausea, diarrhea, cramps, rash, face swelling, temporary reduction in blood cell production

)Post-herpetic neuralgia=>give acyclovir
-follows acute herpetic-zoster infection

)Intra-uterine fetal demise (IUFD)-death in utero>20weeks
-Beta-HCG remaind eleveted
-confirm with US
-first do a coagulation profile to assess the risk of DIC
<=>between 13-28 weeks, no DIC=>watchful expectancy
<=>between 13-28 weeks, with DIC=>induction of labor with PG suppositories
<=>after 28weeks, with/out DIC=>induction of labor with oxytocin and laminaria tents
-can use vaginal delivery
So, in case of DIC=>deliver immediately by induction of labor

)Acute retinal necrosis in HIV patients
-pain, keratitis, uveitis
-peripheral pale lesions+central retinal necrosis
-given by HSV or VZV
CMV retinitis=hemorrhages+granular lesions around the retinal vessels

)Pneumonia after upper GI endoscopy=>suspect anaerobic bacteria=> give clindamycine or ampi+metronidazole
Ampi+genta=used almost NEVER for pneumonia, they are used for abdominal infections+-metronidazole

)Cyclophosphamide=> can give bladder cancer
-prevent by lots of fluids and mesna

)Stress fracture (March fracture) or insufficiency fracture:
-young adults who exercise a lot
-X-ray=normal, dignose it with CT or MRI
-dull pain increased by exercise
-point tenderness
-at metatarsal, navicular, neck of femur/tibia

)Hypothyroidism-consider in patients with unexplained high CK levels

)Bicuspid aortic valves=>can give aortic stenosis later in life (4-5th decade)=MCC of aortic stenosis in middle-aged adults

)Seborrheic keratosis-in the elderly
-0.3-2cm large
-slow enlargement
-greasy surface, stuck on appearance-HIGH YIELD these words
-varies in color
-anywhere on the body, except palms and soles
-can itch or rub
-do shave biopsy (DON'T DO IT FOR MELANOMA)
)Aspirin toxicity-gives metabolic acidosis and respiratory alkalosis (not normal compensation, but two distinct processes)

)Gastroparesis-treat in order by: metoclopramide, bethanecol, erythromycine; also cysapride-but it gives cardiac arrythmias
-confirm study=Nuclear Medicine Scintigraphy

)To determine the type of jaundice (conjugated or unconjugated) do:
-check urnary excretion of billirubin
-Van der Bergh test

)Lyme disease prophylaxis-do it only in pregnant women with hystory of tick bite in order to RELIEVE ANXIETY by Amoxi
-give vaccine to people living in moderate/high risk areas
-to the rest of the population=NO PROPHYLAXIS

)MCC of SAH (subarahnoid hemorrhage) syndrome in children is AVM rupture
-may have a case with hystory of seizures and migraine-like headaches

)Screen patients for lipid abnormalities:
-men>35 years
-women>45 years, if in good health or
between 20-35 (M) and 20-45 (W) if they suffer from:
a)DM
b)family hystory of hyperlipidemia
c)personal risks of CAD
d)family hystory of cardiac disease<50 years (M) or <60 years (W)

)Gout attacks-give:
-low-purine diet
-no alcohol=>metabolises to lactic acid=>impairs renal excretion of uric acid by acidifying the ph
-avoid diuretics, pyrazinamide=>they compete with uric acid for renal excretion

)Penile fracture=emergency
-penis deviated to one side due to the rupture of albugineea of a cavernous body
-first do retrograde urethrogram, then surgical exploration of the penis

)Hypercarotinemia-in anorexia, DM, hypothyroidism

)A confounder (ex.smoking), to be considered so, needs to be linked to the:
-exposure (ex.people who drink alcohol are more likely to smoke)
-outcome (ex. smoking is associated with oral cavity cancer)
So smoking can be a confounder if a study concludes that alcohol alone is responsable for oral or oesophageal cancer!!!

)Effect modification=the effect of exposure (ex.drugs) on outcome (a disease) is modified by another variable (ex.family hystory). This effect is not BIAS!!!

)Amiodarone=> don't give it if low BP
)Lesion suspicious of melanoma=>do excisional biopsy with narrow margins

)Radioactive iodine=treat of choice for Grave's disease
Antithyroid drugs-give in pregnancy+Grave's
-pre-op for surgery on Grave's
Iodinated contrast agents=>treat thyrotoxicosis
-give them if intolerant to anthytiroid drugs
Surgery-if:
-very large goiters
-antithyroid drugs do not control thyrotoxicosis in pregnancy
-increased risk of malignancy
-if next year scheduled pregnancy

)Petrous apicitis-triad=retro-orbital pain, paralysia of lateral rectus, otorrhea

)Anoscopy/proctoscopy=first step for blood per rectum in patients <50 years of age, without risk factors for colon cancer (here's not included blood mixed with stool=this is a risk factor)

)Sickle cell disease-aplastic crisis-prevent by folic acid administartion and NOT by vaccination against parvovirus (which is a nother cause)

)Exercise level in pregnancy=keep it at the same level as before preganancy

)Phenothiazine-gives hypothermia, inhibit shivering-think of a schizo wandering in the streets in winter and is found lying in a park

)If someone exposed to HBV is vaccinated already and HAS a documented response to HBV (by prior adequate titer of antibodies)=>do nothingm, just reassure!!!

)If in 2 weeks from the beginning of a pneumonia, the CXR is still pathologic=> do bronchoscopy and CT scan to rule out abcess or tumor and to take cultures, to drain...

)A reliable test gives similar results on repeat measurements
A valid (accurate) test gives results that can be compared with a gold standard test!!!

)Graft versus host disease=> affects skin (rash), intestin (blood+diarrhea), liver (abnormal LFT)
-by activation of donor T-cells, so it's cell-mediated immune response
)In DKA there's a paradoxycal hyper K+ from acisosis, because the reserves of K+ are actually depleted=> so give K+ in your treatment plan

)FIRST sign of colo-rectal cancer under 40 years of age=Rectal Bleeding

)Removal of K+ from the body=cation-exchange resin (kayexalate), diuretics, dialysis; NOT Ca gluconate, NOT insulin (these create only a shift intracellularly)

)Roth spots and Osler nodulesm in IE are from immune complex deposition (immune vasculitis)
Janeway lesions=septic embolism

)Optic neuritis=rapid vision decrease
-marked changes in color perception
-pain on eye movements
-central scotoma
-afferent pupillary defect
-swollen disk

)Myotonic muscular dystrophy
-begins in childhood (~13 years)
-AD disease
-muscle weakness, wasting in distal hands, post. forearms, ant. compartment of legs
-myotonia=delayed relaxation
-associated with testicular atrophy, DM, frontal balldness, hypothyroidism

)Matitis-in nursing
-treat by anti-Staph penicillin
-continue nursing to decrease breast engorgement and observe
-drainage only if there'sa fluctuating mass (=abcess)

)Atracurium-metabolized in plasma, by serum esterases
-use it safe in renal and liver dysfunctions
Pancuronium+mivacuronium=>not good in renal disease
Rocuronium=>not good in liver disease
Succinylcholine-in renal disease gives Hyper K+ and apneea

)Randomization=similarities in the baseline characteristics of patients in both placebo and treated groups. It controls known/unknown confounders!!!

)Mild acne=>topical retinoids; if reactivation occurs, give topical antibiotics
Moderate to severe acne (papular or inflamatory acne)=>oral antibiotics
Nodulocystic, scarring acne=>oral isotretinoin

)IMPORTANT!!!
In any metabolic acidosis=>first step=get AG (Na-Cl-HCO3); normal is 6-12 (or 8-14 depends on the author)
a)Normal AG metabolic acidosis-usually hyper Cl-2 causes:
-renal loss of HCO3 by RTA, moderate renal failure (GFR>20ml/min), carbonic anhidrase inhibitors
-GI loss of HCO3 by diarrhea, pancreatic fistula, ureterosigmoidostomy
To differentiate between them, get next step=urine AG(Na+K-Cl); normal is from -50 to 0.
If (+)=> defective urine acidification, lower urinary Cl, like RTA 1,2 and 4
If (-)=> higher urinary Cl=>adecquate NH4+ production=> GI causes
Then, urine PH differentiates different types of RENAL causes of acidosis!!!
b)High AG metabolic acidosis:
-lactic acidosis
-ketoacids (DM, starvation, alcohol ingestion)
-methanol ingestion
-ethjylen glycol ingestion
salycilate poisoning
uremia (GFR<20ml/min)
Here, next step is to calculate the osmolar gap (especially if toxicity is suspected)

)Paget disease=disordered skeletal remodelling
Osteoporosis=low bone mass with normal mineralization
Rickets=defective mineralization of bone and cartillage of the growth plate

)Malignant otitis externa-by pseudomonas (in DM, imunocompromized)
-granulations of the ear canal
-involvement of CN VII, IX to XII
-erosion of bone
-foul smelling discharge
-deep otalgia
Rhizopus+Aspergillus are fungal infections that give external otitis, (not malignant), but don't make granulations

)Suspect Zollinger-Elisson syndrome if refractory ulcers are associated with renal stones and there's a + family hystory of PUD

)HIGH-YIELD:
Erythopoietin in dialysed patients-side effects:
-raises BP, even HTN encephalopathy
-headaches
-flu-like syndromes
-red-cell aplasia (rare)
Start treatment at Hematocrit<30% or Hb<10g%

)Gall-bladder pathology-First use US
HIDA scan-for diagnosis of acalculous cholecystitis or suspected on US

)Trichinosis-2 phases:
a)GI upsets:pain, nausea, vomit, diarrhea
b)splinter hemorrhages, retinal&conjunctival hemorrhages, periorbital edema, chemosis, muscle pain, tenderness, swelling, weakness

)Eato-Lamber syndrome-earliest manifestation is hip-girdle weakness, later shoulder girdle involvement

)Thioridazine toxicity-cardiac arrythmias, prolonged QRS, low BP, tahicardia; treat by NaHCO3

)Sputum gram stain of pneumonia-purulent specimen if >25 neutrophils and <10 epithelial cells/field

)Respondent bias=when outcome is obtained by patient's response (ex.migraine) and not by objective means of diagnosis (ex.biopsy)

)Tinea corporis infection-itching
-ring-shaped scaly patches with centralclearing and distinct borders
-caused most frecq. by Trichophyton rubrum
-treat by topical terbinafine
-use griseofulvine if only extensive disease (this drug is usually not used today)


)Salivary glands inflamation-from drugs such as: tioureea, iodine, cholinergic drugs

)Hepatitis B-associated with membranous GN
Carrierrs of Hep. B virus-associated with membrano-proliferative GN

)Vit.K deficiency:
-NPO patient
-receiving antibiotics
-high PT, then high PTT (prolongation of PT>> prolongation of PTT)

)Primary sclerosing cholangitis-in Ulcerative Colitis
-complication of it is cholangiocarcinoma=contraindication to transplant
So any severe stricture of the biliary tree MUST BE BIOPSIED!!!

)Mitral regurgitation=MC valvular abnormality in patients with IE

)Hollenhorst bodies=cholesterol particles, signs of impending stroke

)Benzodiazepines-can cause paradoxycal agitation in the elderly

)Congenital cataract=MCC of white reflex in pediatric population

)Any nocturnal, newly diagnosed asthma in middle-aged patients=>suspicion of GERD if associated laryngitis; to differentiate between asthma and GERD give a trial of proton pump inhibitors which can be both dignostic anf therapeutic

)CREST syndrome-may have pulmonary HTN (loud P2 sound)
)Mechanical symptoms in patients with meniscal problems=>evaluate by arthroscopy or MRI, then correct by surgery (arthroscopic or open)

)Latent period-in chronic disease epidemiology; is NOT BIAS
=extended time of continuous exposure is needed to affect the outcome (ex. 2 years of continuous multivitamins administration is needed to give a protective effect against cancer)

)Nitrates are c.i. for at least 24h after taking sildenafil (viagra)

)SCC-scaly plaque, central ulceration, 1.5cm, on the forearm
-polygonal cells, atypical nuclei at all levels of epidermis, zones of keratinization; sometimes is difficult to tell it apart from BCC

)Hypo K+ metabolic alkalosis:
-vomiting=>low urine Cl
-S. Bartter
-S. Gitelmann
-diuretic abuse; all three have high urine Cl

)Otosclerosis-AD disease
-Women>>men
-more in Caucasian race
-treat by NaF

)Lactose intolerance-diagnose with Lactose Breath H+ Test or (+) Clinitest for stool reducing substances
-high osmotic stool gap=290-2(stool Na+stool K)>50mosm/kg

)Goodpasture's syndrome-give emergent plamapheresis!!!

)Metastatic bleeding brain mass=> FIRST think MELANOMA
Tumors that don't metastisize to the brain are:
a) non-melanomatous skin cancer
b) oropharingeal cancer
c) oesophageal cancer
d) prostate cancer


)Parkinson's tremor=>gibe benztropine
Choreea Huntington=>give haloperidol

)Vitreous hemorrhage-sudden, acute loss of vision
-sudden onset of floaters
-fundus is hard to visualize, floating debris, dark red glow
-treat conservatively-sleep in upright position

)Prematurity-cause of intraventricular hemorrhage

)Mamography-do it annually between 50-75 years
FOBT-anually; 50-80 years
sigmoidoscopy-every 5 years between 50-80 years
Pap smear-until the age of 65 years, not after
Lipid screening-men>35y
-women>45y
-not >75y
-??unknown recommendations between 65-75y

)Alpha-1 antitrypsine deficiency in non-smoker, 3rd decade of life, lower lobe emphysema, neonatal jaundice in hystory

)Relapsing polychondritis
-recurrent inflamation of cartillaginous structures: ear=MC,spares the lobules; eye (conjunctivitis, episcleritis); joints (diffuse joint pains); skin; CNS.

)Fracture of calcaneum due to fall=> evaluate for other potetial fractures by X-ray of head, chest, abdomen, lumber area and pelvis
It's a very painful fracture and prior taken narcotics may alter pain perception
-so give morphine in severe pain, but after investigating for potential injuries (head and neck first)!!!

)Li-can cause seizures, opisthotonus, hyperreflexia, coma

)Attributable risk percent (ARP)=risk in exposed-risk in unexposed/risk in exposed=1-risk in unexposed/risk in exposed=1-1/RR=RR-1/RR
-it's the excess risk in the exposed population attributable to the risk factor!!!

)Impaired NH4+ excretion=main mechanism of metabolic acidosis in renal failure

)Hypo K+ periodic paralysis-by stress or medication
-sudden drop in K+ levels
-renin=normal, BP=normal
-familial condition or thyrotoxicosis

)Bartter syndrome=hypoK+ metabolic alkalosis
-impaired Na absortion in Henle ascending loop=hypovolemia=>activate RAA syste
-polyuria, polydipsia, growth abnormalities
-high urine Cl

)Serous otitis media=>air bubbles seen in the middle ear
Cholesteatoma-marginal tympanic membrane perforation, ear canal filled with mucus, pus, granulation tissue, destroys bone; remove surgically

)All patients suspencted of Zollinger-Elisson syndrome should have checked:
-first: serum gastrin levels (if>1000pg/ml are diagnostic); if not diagnostic,
-then:secretin stimulation test, if (-),
-then: Ca infusion study
Also measure gastric PH once to exclude hypergastrinemia from achlorhydria

)Chlamydial urethritis-dysuria, urinary frecquency
-mucopurulent urethral discharge
-sexual hystory of multiple partners
-pyuria+absence of bacteria on urialysis (colonies<100/ml)
In gonochoccal, the discharge is purulent!!!

)Differentiate CML from leukemoid reaction by measuring Leukocyte Alkaline Phosphatase (LAP); low in CML, high in leukemoid reaction!!!

)Lewy body dementia-fluctuating cognitive impairement
-reccurent visual halucinations
-motor features of Parkinson

Pick's disease-fronto-temporal
-personality changes (euphoria, dezinhibition,apathy)
compulsive behaviour
-peculiar eating habits, hyperorality
-impaired memory
-visuo-spatial function=intact

)Transient synovitis of the hip:
-X-ray=normal
-2 weeks after URI
-high ESR
-pain of joint movements
-treat by bed rest and hip joint in the position of comfort

)Beta-blockers intoxication-treat by:
-atropine, if fails
-isoproterenol, if fails
-glucagon

)Gold standard for osteoporosis is DEXA scan

)Increased ventilatory rates onmechanical ventilation=>can lead to auto-PEEP=>lowers BP
-treat by decreasing the ventilator rate

)Erythema nodosum-may be the first sign of sarcoidosis
-goes with flare-ups of IBD
-appears in TB too

)Osgood-Schaltter disease-treat with rest, NSAID, brief casting

)Beta-blockers-selective beta 1 are agents of choice for perioperative MI risk decrease

)Cocaine abuse-young, venous trace marks, EKC with ischemia (ST depression), tahicardia, HTN
-treat-first line: Benzodiazepine, then nitrates, aspirin
-do catheterisation only if MI is obvious!!!

)Use aspirin in children only in:
a)Kawasaki disease
b)Juvenile rheumatoid arthritis

)Patients on both Mg(OH)2 and Kayexalate can get metabolic alkalosis due to the fact that Kayexalate bind Mg, so HCO3 remains in access and can be reabsorbed from GI tract!!!

)Treatment of hypo Na (SIADH):
-mild, asymptomatic, Na=120-130: fluid restriction
-moderate, asymptomatic, Na=110-120: normal saline+loop diuretic
-severe, symptomatic: hypertonic saline (3%)+loop diuretic

)Laxative abuse-10-20 evacuations/day and night,cramps=cause of factitious diarrhea
-on colonoscopy you see melanosis coli, because of the use of anthraquinone-laxatives (bisacodyl) and is dark-brown discoloration of the colon with shining limph follicles as pale patches

)Cyclosporine side effects=HIGH YIELD:
a)nephrotoxicity, high K+
b)HTN-tret with Ca channel blocker
c)neurotoxicity-tremors
d)glucose intolerance
e)infections
f)malignancy
g)gingival hypertrophy, hirsutism
h)GI complaints
Tacrolimus-same side effects except no gingival hypertr. and no hirsut.
Mycophenolate=>bone marrow suppression
Azathioprine=>bone marrow suppression,hapatotoxicity, diarrhea, leukopenia

)Pernicious anemia=>has high levels of LDH

)Nosocomial pneumonia in intubated patients=>think Pseudomonas=>give cefepime or ceftazidime (4th generation)

)A definite diagnosis for Alzheimer's disease can be made only post-mortem by brain biopsy!!!

)Chronic fatigue syndrome-like fibromialgia,but no trigger-points+symptoms of at least 6 months duration

)Barton's fracture-intraarticular, carp+distal margi of radius
Chauffeur's fracture-of radial styloid
Galeazzi's fracture-anywhere on the radius+radio-ulnar junction
Smith's fracture-reverse Colles fracture

)Null-hypothesis for cross-sectional study:
There's no association between elevated ESR level and colon cancer!
Null-hypothesis for cohort study:
The risk of colon cancer is the same for the subjects with and without elevated ESR level

)Descending aortic aneurysm in a young male is frecq. due to blunt trauma to the chest!!!
HIGH-YIELD:

)Bullous penphigoid=IgG+C3 deposits at the dermal-epidermal junction
-no oral lesions
-tense blisters in flexural areas
->60 years of age
-pruritus precipitated by UV, NSAID, antibiotics

Pemphigus vulgaris-intraepidermal blistering disease with auto-antibodies to adhesion molecules
-Ig G deposits intracellularly in the epidermis

Cicatricial pemphigoid-affectsmucous membrames
-Ig G deposits in linear band at the deromo-epidermal junction

Herpes gestationis-2nd trimester
-sub-epidermal blisters
-deposits of C3 at the basement membrane zone

)Amphotericine=>can give hypoK+

)Hshimoto thyroiditis:
-low TSH, high T4, T3, high T3 resin uptake
-low radioactive iodine uptake
-high thyroglobilin level
-non-tender goiter
-dry mouth&eyes

)Leukoplakia:
-increased risk of SCC
-from tabacco, vit. A, B deficiencies, syphilis
-do incisional biopsy or exfoliative citology examination!!!

)Soemtimes UC can involve the terminal ileum=>backwash ileitis

)Adult PKD complications:
-hepatic cysts
-valvualr heart disease (MVP, AR)
-colonic diverticula
-abdominal wall and inguinal hernia

)Thrombastenia Glanzmann-RA disease
-defect in GP IIb-IIIa
-increased BT
-trombocytes=normal, vWF=normal
-clot retraction is decreased
-epinephrine, colagen, thrombin and ADP fails to induce aggrgation
-normal response to ristocetin test
Bernar-Soulier syndrome-giant trombocytes, bleeding tendencies
-lack of aggrgation to vWF and ristocetin
-normal responde to ADP
-abnormality in GP Ib

)Acalculous cholecytitis:
-extensive burns
-severe trauma
-prolonged TPN
-prolonged fasting
-mechanical ventilation

)HIV patients with esophagitis-give fluconazole against Candida; if it donesn't cure, then and only then do esophagoscopy, cytology, biopsy, culture!!!

)In alkali ingestion(ex. lye)=>do contrast study with gastrografin+endoscopy as easrly as possible
-don't give charcoal=ineffective!!!

)Bupropion-can be given with nicotin patches, monitor BP=>risk of HTN
-causes weight loss
-risk of seizures=>don't give to anorexic patients as antidepressant

)In tumor lysis syndrome=>give allopurinol+hydration!!! If on allopurinol, give only 25% of purine antagonists (mercaptopurine, azathioprine)!

)In heat stroke=>rapid cooling with evaporating cooling=choice,then gastrci lavage or imersion in cold water

)Dermatitis herpetiformis=>dapsone

)In metab acidosis=>look for compensation (PaCo2)=>look at AG=>look at variation of AG and HCO3; one goes up and the other should go down, if this is the only acid-base problem, so the divisation of their variations is equal to 1!!!

)Prevalence high=>high PPV, low NPV

)Nickel jewelry, poison ivy=allergic contact dermatitis (type IV reaction)

)Do thyroid function tests if:
-hyperlipidemia
-unexplained low Na
-high CK levels

)Treat strep.pharingitis with one shot of benzatin-penicilline G i.m.

)MC complication of PUD=hemorrhage

)MC drug causing priapism=prazosin

)Asymptomatic lymphocytosis in older=>suspect CLL=> lymphadenopathy=>hypogamaglobulinemia=infections!
-Smudge cells are characteristic
-lymph node biopsy is not required for diagnosis, but it confirms it!

)In primary billiary cirrhosis-give ursodeoxycolic acid=first line, second-line=cholestiramine; ultimate cure=liver transplant



)Actinomycosis-anaerobic gram (+) branching bacteria
-draining infection, indurated area
-sulfur granules
-treat by high dose penicilline or erythromycine 6-12 weeks!!!
Another cause of draining face/neck infection=scrofula!

)Scoliosis-Cobb's angle
-mild curve<20degrees=>careful follow-up to assess the rate of progression
-20-30 degrees=>choice between observation and bracing is made on the presence of rotational deformity and + family hystory
->30 degrees=>bracing
->40degrees=> surgery

)Unacceptability bias=participants' response with desirable answers which leads to underestimation of the risk factors-ex. medical students are asked to complete a survey about whether they smoke or not...some may say that they don't smoke just because they know that smoke is bad for health!!!

)Hystory of normal skin at birth+gradual progression to dry scaly skin=ichthyosis
-dry skin with horny plates over the extensor surfaces of the limbs
-worsens in winter due to increased dryness=lizard skin!

)Markers of adrenal tissue: DHEA, DHEA-Sulfate
Testosterone+androstendione coem equally from ovaries and adrenal glands

)Symple renal cyst on CT=>reassurance (know the CT appearance), but investigate if:
-multilocular mass
-thcikened irregular walls and septae within the mass
-contrast enhancement

)In mononucleosis, patients can play sports only when physical exam is normal (no splenomegaly)

)TIA-give anticoagulation if embolic
-in the rest, give aspirin; if fails, give clopidogrel, if fails, give ticlopidine
-aspirine+dipiridamole-if there's a hystory of TIA on aspirin alone

)Zellweger's syndrome-defect in peroxisomes
-neonatal seizures
-facial dysmorphism
-hypotonia, wide open sutures, cloudy cornea, glaucoma
-they live only a few months

Neonatal adrenoleukodystrophy-no dysmorphic features
-enlarged liver, abnormal LFT, pigmentary degeneration of retina, impaired hearing

X-linked adrenoleukodystrophy
-accumulation of fatty acids (log chain ones)=>pregressive adrenal cortex dysfunction and CNS white matter

Infantile Refsum disease
-gait problems, hearing loss, pigmentary degen. of retina, dysmorphic features

Classic Refsum disease-young adulthood
-visual problems (night blindness), ataxia, cardiac arrythmia, ichthyosis, peripheral neuropathy

)Osteoporosis-acute backpain with noobvious preceding trauma in the elderly women=compression fractures of the vertebrae

)More than 5 days of symptoms of appendicitis with RLQ findings=>give iv. hydration, antibiotics (cover gram (-)), bowel rest

)Chronic therapy with Vit. D=>hyper Ca
-stop vit.D, low Ca diet, acidify urine, give corticosteroids!



)To control confounding-means:
-matching
-randomization
-restriction
Selection bias=>controlled by selecting a representative sample of the population for the study+high rates of follow-up
Ascertainment bias=>avoided by a strict protocol of case ascertainment
Observer's bias=>controlloed by blinding

)Patients with dyspepsia and <45 years of age without alarm symptoms (bleeding, anemia, dysphagia, weight loss)=>first step=Non-invasive test for H.pylori (breath test or serologic test)
-if +=>eradication therapy of H.pylori
-if -=>empirical trial of H2 blockers or PPI or prokinetics
If >45 years or with alarming symptoms=>do endospcopy+H.pylori testing

)Hematuria+irritative or voiding symptoms=>suspect bladder cancer, even in a patient with large, firm prostate
-associated factors: cigarette smoking, suprapubic pain, long hystory of analgezic use

)Chronic ITP-can be a feature of SLE; that's why in chronic cases of ITP=> do BM biopsy

)In conjugated hyper bilirubinemia=> first do LFT, then US of CT scan

)Dubin-Jonhsons+Rotor syndromes=> have normal ALP

)Hawthorne effect=tendency of the studied population to affect the outcome due to the fact that they are being studied!!!
Sample distorsion bias=when the sample is not representative for the whole population in "exposure" and "outcome"
Information bias=imperfect assessment of association between exposure and outcome as a result of errors in the measurement of exposure and outcome-it's minimized by standard techniques for surveillance and measurement+trained observers

)HIGH-YIELD:
Left ventricle dysfunction: high RA and PCWP pressure
Septic shock: low PCWP and RA pressure, low SVR, high debit
In pericarditis, tamponade=>RA pressure=PCWP and both are high
RV infarct=> low PCWP, low BP

)Post-prandial worsening pain+avoidance of food+risk factors for atherosclerosis=abdominal angina

)Hydatid cysts-Echinococcus granulosus
-asymptomatic
-mostly in the liver, but also lung
-comes from sheep
=fluid-filled cyst with numerous secondary daughter cysts
Pig farmers=> get neurocysticercosis
Commercial sex-worker=>can get perihepatitis from STD (gonorrhea)

)Congenital adrenal hyperplasia-hirsutism, virilization+very high levels of 17-HO-progesteron, normal Testosteron and DHEA
Idiopatic hirsutism-from excessive peripheral conversion of testosteron=>dihidro-testosteron

)If bleeding >25-30% of blood volume (or 1500ml)=>give blood transfusion
In trauma, usually give 2l of crystalloid solution in 10 min=>if still hypovolemic=>give blood
Give blood also if:
-Ht<25%
-Ht<30%+ COPD, Ischemic Heart, chronic renal failure
-unexplained acidosis in anemic patients

)Epiglotitis=>first do fiberoptic laryngoscopy to establish a diagnosis, then do nasotraheal intubation (alternative=traheostomy)

)HIGH-YIEDL-Know this thouroughly!!!
low PCWP, normal MV02 (mixed venous O2 concentration)=>is septic shock; also: low RA pressure, high debit, low SVR
low PCWP, low MVO2=>is volume depletion or neurogenic shock
)Atopic dermatitis-infants<6 months
-pruritus
-symmetrical-scalp, cheeks, trunk, extensor areas
-unknowun etiology
-in acute attacks give low-moderate potency corticosteroids
-spares diaper area (contact dermatitis does not)

Exfoliative dermatitis-over 40 years of age
-prior dermatological condition, systemic illness, new medication

)Dehydration in diabetes insipidus=>give normal saline; once the volume deficit is replaced, can switch to 0.45% saline to restore water deficit

)HIGH-YIELD
CT scan=>use it to evaluate the extent of newly diagnosed gastric cancer; treat by surgery

)In dialysis-persist or worsen the followings: anemia, HTN, bone disease, autonomic neuropathy

)Intrahepatic cholestasis of pregnancy
-3rd trimester with jaundice
-marked pruritus, high AST, ALT(<200), very high bile acid levels, ALP<200, PT=normal

)If suspect IUFD=>GET US, then coagulation profile

)Spontaneous hemarthrosis=>think hemophilia

)Osteogenesis imperfecta=>get type 1 collagen assay

)If one parent gives consent for the treatment of a minor is sufficient 9even if the other one disagrees)=>go ahead with the treatment!!!
If both parents refuse treatment=>get a court order if the situation is not emergent!!! If it's emergent=>treat as you see fit; you are protected by the law that you act in the best interest of the child!!!

)Inhaled steroids=> can give dysphonia, thrush

)In a ureteral colic, one can have intestinal ileus=>do CT scan or IVP; treat by ureterolithiasis
Enteroclysis=used to diagnose small bowel tumors or other pathology which cause intestinal obstruction

)In case-control studies, if prevalence of the disease is low=>odd ratio=~RR (this is rare disease assumption). They love these questions, try to understand them, though they are difficult!!!

)Study of choice for abdominal aortic aneurysm=abdominal US

)Malignant melanoma-MC as a changing mole
-hystory of sun exposure
3 major crteria:
change in-color
-shape
-size
4 minor criteria:
inflamation
bleeding/crusting
>7mm
sensory changes

)In metabolic alkalosis from vomitting=> give K, not Ca which is normal in total, only ionized is decreased

)In acute respiratory alkalosis=>PH raisis the afinity of Ca for albumin=>decreased ionized Ca, increased albumin-bound Ca, normal total Ca and normal Ca bound to inorganic anions

)Chronic pancreatitits with central duct>1cm and severe pain=>do lateral pancreatico-jejunostomy

)Alcoholism=>can cause rhabdomyolysis (drunk man lying in a park)=> urine dipstick is + for blood but (-) for RBC=>from myoglobinuria

)IE of drug users: give vanco+genta because of high incidence of meticillin-resistant Staph
-if not drug abuser=>give naph+genta

)Acarbose (alpha glucosidase inhibitor)=> don't allow carbohydrate breakdown in the intestin=>high carbohydrates in the stool!
-indicated in late onset type II DM

)Dysphagia to both solids&liquids=>achalasia=>domanometry, but alsoendoscopy to rule out cancer

)Acute monicitic leukemia- M5A in young (~16 years)
- M5B-middle age(~49 years)
-(+) alpha-naftyl esterase
-numerous promonocytes and monocytes
M3 leukemia-assoc. with DIC

)Post-op benign intrahepatic cholestasis
-after major sugery
-low BP
-extensive blood loss
-or after massive blood replacement

Halothane toxicity-type 1-mild elevation of LFT, no jaundice
-type 2-acute liver failure

)Kaposi sarcoma-on the trunk, face, extremities
-papules>plaques/nodules
Bacillary angiomatosis-like Kaposi sarcoma, but with systemic signs (malaise, headaches, fever)

)Prolactin is (+) by TRH, serotonin and (-) by dopamine
Hyperprolactinemia=>(-)GnRH=>amenorrhea
=>galactorrhea
Both of them appear in hypothyroidism due to high TRH

)Idiopathic pulmonary fobrosis-treat by steroids; lung transplant is not an option since it must be bilateral and there's a shortage a donors!

)In fibromyalgia=>check thyroid tests and CK levels
Diffuse axonal injuries-from deceleration
-at the gray-white matter junction
-looses consciousness on the spot=>then persistent vegetative state
MRI is more sensitive than CT for detecting the axonal injuries

)Lumbosacral strain-pain after exertion
-absence of radiation
-(+) paravertebral tenderness
-(-) straight-leg raising test
-normal neurologic exam

)Situational syncope: middle-aged, old male, losses counsciousness immediately after urination or during coughing fits

)Hypocalcemia-after major surgery, extensive transfusions
-due to volume expansion, hypoalbuminemia
Mypo Mg-alcoholism
-diarrhea, diuretic abuse
-prolonged NG suction
)Management of DM foot ulcer from mild to severe forms:
-off-loading
-debridement
-wound dressing
-antibiotics
-revascularization
-amputation


)In refractory ascites=>do tapping of up to 2l/day+give 10g albumin/liter taped as a last resort before any surgical procedure you may think!!!
Spleno-renal shunt-will worsen ascites
Side to side porto-caval shunt-improves ascites, worsens encephalopathy
Peritoneo-jugular shunt-for the treatment of ascites only; risks:DIC, sepsis, peritonitis
iv furosemide therapy=>worsens encephalopathy, precipitates hepato-renal syndrome

)Treat Ca-oxalate stone lithiasis by:
a)increased fluid intake>3l
b)normal or increased Ca intake-yes!!! you read fine!!! (1000mg)
c)low Na diet
d)low oxalate diet (no chocolate, vit C)
e) low dietary proteins (meat, eggs)

)Soap-bubble appearance in the distal femur on x-ray with knee pain, some mass, in 20-40 years old=>think giant-cell tumor of the bone=>refer to orthopedic surgeon; don't do bone scan=this is for solid tumor metastasis identification

)Choledocal cyst=congenital anomaly of the biliary tree
-dilatation of the intra/extra hepatic ducts
-jaundice, acholic stools
-reccurent attacks of pancreatitis
-can degenerate into cholangiocarcinoma
-First do US, then CT or MRI
Caroli'ssyndrome=congenital
-intrahepatic dilation of bile ducts

)In transplant patients=> give TMP/SMX to prevent PCP pneumonia; alternatives:dapsone or aerosolized pentamidine

)Lumbar pain in the 3rd trimester=> due to lumbar lordosis and relaxation of the ligaments of the sacro-iliac joints

)Dystonia-treat by benztropine or diphenilhydramine

)90% of PE come from emboli in the ileo-femoral veins

)Pseudogout under 50 years=>think any of:
hypo Mg, hypo P, hyper PTH, hypothyroidism, hemochromatosis

)Treat fractures of the humeral shaft by: closed reduction and immobilization of the arm in a hanging cast

)Cystic fibrosis-may develop Cl sensitive metabolic alkalosis
Barter'syndrome-Cl resistant metab. alkalosis

)In GERD=> give empirical treatm. with PPI or H2 blockers=>if it fails or there are features of complicated disease=>esophagoscopy=>if (-)=>PH monitoring

)HIGH-YIELD
Acute tubular necrosis-muddy-brown cast
GN-RBC cast
Pyelonephritis, interstitial nephritis-WBC cast
Nephrotic syndrome-fatty cast
Chronic renal failure-broad, waxy cast

)Febrile reaction to transfusion=>prevent it by Le depletion with cell washing

)Chronic Hep C with normal enzymes=>follow yearsly with LFT, not biopsy!!!

)Biophysical profile (BPP); N=8-10
-if AFI<5=>deliver because of possible cord compression
-if BPP=6 and no oligohydramnios=>do CST, if non-responsive=>deliver; if suspicious=>repeat CST in 24h
-if BPP=4, no oligohydramnios and fetal lungs are mature=>deliver; if not mature=>give steroids and do BPP in 24h
-if BPP=2=>deliver no matter what!!!

)Cyclical vomiting-in children with parents with headaches
-no obvious cause

)Contraindications to exercise stress test are:
LBBB
ST>1MM
WPW Syndrome
idioventricular rythm
**but NOT: RBBB, ST depression at rest<1mm

)Ehylene glycol poisoning-has Ca-oxalate rectangular, envelope shaped crystals
-high AG=>SO WHAT DO YOU DO???
-Osmolar Gap=observed osm-calculated osm
calculated osm=2Na+Glu/18+BUN/2.8

)Chronic painful DM neuropathy: give TCA, NSAID or GABAPENTIN=CHOICE

)Constipation with back pain, renal dysfunction, high ESR,anemia=>what is it?????
Multiple myeloma, where the constipation is from hyper Ca; also polyuria, anorexia.
Similar scenario from metastatic bone cancer=>think Hyper Ca as a cause for constipation!!!! HIGH-YIELD

)Still HIGH-YIELD
MC nephrotic syndrome in Hodgkin disease=minimal change disease
In general membranous GN is associated with carcinoma

)Disseminated hystoplasmosis-in imunosupressed people
-low fever, wieght loss
-hepatosplenomegaly, mucous membrane ulcers
-pancytopenia, pneumonia

)Lichen sclerosis-post-menop
-treat by superpotent topical corticosteroids
Any itchy spot on vulva post-menop=>needs biopsy!!!

)To diagnose polymiositis=muscle biopsy

)Blunt abdominal trauma with negative US and CT scan=> do DPL to detect small lacerations; if also (-
)=>observation is next!!!

)In DM goals are BP<130/80mmHg

)Carpal tunnel syndrome-associated with hypothyroidism

)Toxic epidermal necrolysis-mucocutaneous
-(+)Nikolsky sign
-painful skin lesions
-idiosyncratic reaction to sulfonamides, barbiturates, phenitoin
KNOW THE PICTURE!!!
Steven-Jonhson's syndrome=target lesions on >2 of mucosal surfaces; also from sulfonamides, NSAID, phenitoin

)Cirrhotic with fever, abdom. pain, ascites=spontaneous bacterial pneumonia!!!
-do paracentesis to confirm: Le>250/ul, protein>2.5g/l, specific gravity>1016, serum/ascitic protein<1.1

)Metastatic breast cancer with solitary metastase=>do surgery (resect it)
Pulmonary metastasectomy-do it if:
a)primary tumor is out
b)no other sites exist
clow operative risk
d)complete resection is possible
In widespread disease=>hormone or chemotherapy!!!

)Pseudopancreatic cyst<5mm, usually resolves on its own in 6 weeks

)Cystic fibrosis with pneumonia=>think Pseudomonas
-treat by: pipracillin+genta/cipro (cipro not in children) or cephalosporine (4th gen.)+aminoglycoside


)Pregnancy-high total T3 adn T4, nornal free T4, T3, TSH=normal
-due to increased TBG

)Intermitent explosive disorder-episodes of aggersive impulses with assaultive acts or destruction of property
-degree of aggressiveness is disproportionate with any stressor
-treat by symptoms-if manic:Li, if depressive:SSRI

)Tricuspide valve endocariditis=>can give pulmonary infarct or abcess
-on CXR=well circumscribed elsion with cavitation
-look for this if there's a drug user!!!

)Gonorrhea=>migratory asymmetric polyarthralgias,then a monoarticular arthritis
-skin lesions: multiple necrotic pustules over palmes and soles

)Zn deficiency:prolonged TPN, diarrhea
-alopecia, diarrhea, oligospermia, dysgeusia, rash around the mouth+eyes, mental changes,impaired wound healing
Selenium def.:-cardiomyopathies,skeletal dysfunction
Copper def.:kinky hair syndrome, dissecting aortic aneurysm
Essential fatty acid def.: low thrombocytes, eczematous rash

)Erysipelas-raised sharply demarcated advancing marigins lesion
-on the face
-regional lymphadenopathy
-hystory of trauma or pharingitis

)Subacute lymphocitic thyroiditis-painless
-small goiter
-no ophtalmopathy
-after receiving amiodarone, INF-alpha, IL2

)HIGH-YIELD
Giardiasis-from a developing country
-Rockies
-adhesive disks and malabsortion
-fatty stools, foul smelling, bloating

)Membranous-proliferative GN-caused by Ig antib (C3 nephritic factor) against C3 convertase of the alternative C pathway=>persistent C activation!!!

)In HIV patients-treat histoplasmosis by amphtericin B and then life-long itraconazole

)Dejerine-Roussy syndrome (thalamic stroke): severe dysesthesia, athetosis, transient hemiparesis

)Imipenem+cilastin=second line drugs for Pseudomonas, first line=cephalosporines

)MC lipid anomaly in hypothyroidism=hypercholesterolemia, then hypercholesterol+hyper TG

)D-xylose absortion test is abnormalin bacterial overgrowth and Whipple disease; if you want to tell them apart give antibiotics; they will cure the overgrowth and normalize the test!!!

)First sigh of renal involvement in DM=hyperfiltration
First change that can be quantitated in renal DM=thickening of BM

)HCV-RNA=most sensitive test for diag. HCV infection=gold standard
Anti-HCV antib (ELISA)=very specific

)E.coli urinary infection does not change ph; Proteus DOES=>alkalin

)In brain dead people-deep tendon reflexes can be present due to spinal
activity

)High AFP=neural tube defects (NTD), GI defects=>get acetylcholinesterase level-it''s increased only in NTD


)MSAFP -screening
Down's syndrome: high beta-HCG, low AFP and UE3
Trisomy 18 (Eduard's syndrome): low beta-HCG, low AFP and UE3

)Guillan-Barre syndrome-treat by human IG and plasmapheresis

)Share information about a patient disease only after he/she signed
an official consent to release information!!!
Only if the diagnosis is a risk for the co-workers=>breech confidentiality!!!

)Severe asthma attack: normal/high PaCo2, speech difficulty, diaphoresis, altered sensorium, cyanosis, silent lungs, paradoxycal diafragmatic movements
)RV infarction-elevation of ST in DII, DIII, aVF, V4R, V6R, also elevation in DIII>than in DII
-loss of diatolic function gives rise to RV infarction sysmptoms!!!

)Leydig cell tumors=>high estrogen, testosteron
Yolk-sac tumors=>high AFP
Choriocarcinoma=>high beta-HCG
Seminoma-normal markers usually; also in teratoma!!!

)Hystory of hepatitis+objective hapatomegaly now+weight loss, mild abnormal LFT=>think Hepatocellular Carcinoma=> get CT scan

)Mononucleosis like symptoms with atypical lymphocytes=CMV infection
)MC site of obstruction of emboli is lateral striate arteries=arteries of stroke

)Missed abortion in the I trimester:
-arrest of uterine growth
-beta-HCG level lower than normal
-cervix closed
-no fetal heart tones
-disappearance of nausea and vomitting
Before 16 weeks do D&C,after that induce labor or wait forit to come if there is no DIC!

Threaten abortion-rest and do US 1 week later
Complete abortion-follow with serial HCG to see if it returns to 0

)Laringomalacia-"epiglotitis rolling in from side to side"
-self-limiting
-subsides by 18 months of age!
-noisy breathing when cries or supine, improves in prone position
-feed him/her in upright position

)Unstable trauma patient, no bleeding source identifyable=>do DPL or US of abdomen; CT only when stable!!!
If there are signs of abdominal irritation (peritoneal signs) or penetrating injuries=> first=exploratory laparotomy!!!

)Male hypogonadism=>first check testosteron level
If low=>check FSH, LH
High FSH, LH=primary hypogodism>stimulates testosteron aromatase=>high estradio levels
Low FSH, LH=seconday hypogonadism=>think pituitary tumor=> check prolactin level (even if no gynecomastia)

)Metastatic cancers+x-rays lytic lesions=>give pamidronate=choice for mild/moderate hyper Ca!!!

)If a woman gets pregnant<3months from Rubella vaccine=>treat by reassurance!!!

)Pseudotumor cerebri-risk factors:OCP, corticosteroids, trauma, weight gain, high doses of vit. A
-first exclude space occupying lesions
-treat by lumbar punctures

)In PCOS- levels of DHEA may be high, ACTH=normal, but ACTH stimulation test gives an exaggerated response due to a very high sensitivity of the adrenal glands to ACTH!!!

Adrenal tumors=very high DHEA unaffected by ACTH test!


)Eibstein anomaly-from Li
=atrialisation of RV=> reduced size of RV

)Sleep apnea=> dopolysomnography test; if inconclusive, do multiple sleep-latency test
Lateral cephalometry or MRI-do prior to surgery of the pharinx!

)Pain in the big toe, discoloration, cyanotic,tender, COLD, intact pulses, livedo reticularis bilaterally, high ESR, low C,eosinophilia-what is it???
Blue-Toe Syndrome=cholesterol embolization syndrome!!! HIGH-YIELD
Erythromelalgia=dilation of peripheral vessels with bilateral burning, pain on palms and soles=>to an entire extremity
Reflex sympathetic dystrophy=burning pain in an area with hystory of trauma!!!

)Wounds that fail to heal=>suspect malignancy; SCC on burn wounds (Marjolin's ulcers)

)VT and stable=>give lidocaine or amiodarone=CHOICE

)In DKA give NaCO3 if:
-ph<7.1 (or 7.2 according to others
-severe hyper K
-HCO3 level<5mEq/l

)In toxic megacolon of IBD=>Corticosteroids=CHOICE or emergent surgery: subtotal colectomy with end-ileostomy

)Pericarditis in any renal failure patient (even post-strep nephrtic syndrome)=indication of dialysis

)Cryptorhidism-delay surgery until 1 year of age
-in prematures, add the months of prematurity (born at 6 months, do operation at 3+12=15 months)

)In Budd-Chiari syndrome, investigation of choice=Duplex doppler imaging!!!

)Gonorrhea-can give a sore throat!

)Maternal of fetal deterioaration, regardlessof gestational age=> immediate delivery (vaginally if possible)!!!

)In severe preeclampsia=> first stabilize the patient-bde rest, low salt diet, antihypertensive drugs
-when stable decide:-if at term, fetal lungs mature=>deliver; if remote from term=>wait until 34 weeks for fetal lung maturity

)HIGH-YIELD
Incidence of mania:
-general population=1%
-dyzigotic twins or one parent with bipolar disorder=20%
-both parents with bipolar disorder=60%
-monozygotic twin=70%
So incidence of familial occurence for mania=20%

)Gout attacks in:
-diurectics, niacin, alcohol
-psoriasis
-chronic renal failure
-hemoglobinopathies
-myeloproliferative disorders

)Mild head injuries-low risk=>send home if somebody can look after them
-moderate risk (loss of counsciousness)=>get CT scan and discharge if norma with a "head sheet" list for symptoms that warrant return to the hospital
Moderate to severe head injuries-admit the patient and monitor neurologic signs every2-4h+get CT scan too

)To screen for HCM in all first-degree relatives=>do echocardiography, not by hystory or physical examination=use thisin athletes




)MCC of bleeding in the elderly=diverticulosis;
Second-most common=angiodysplasia/vascular ectasia-painless bledding
-association bet: angiodysplasia and renal failure and also with aortic stenosis
-colonsocopy:cherry-red fern-like pattern of blood vessels that radiate from a central feeding vessel

Ischemic colitis=abdominal pain!!!

)Mixed cryoglobulinemia=palpable purpura, GN, arthralgia, systemic symptoms, hepatosplenomegaly, peripheral neuropathy, low C
-in hep. C infection

)Primary biliary cirrhosis-90% are women
-pruritus=first symptom
-very high cholesterole, ALP, IgM
-mild elevation of AST/ALT
-presence of anti-mitocondrial antibodies

)Tick borne paralysis-rapidly progressive ascending paralysis- over hours to days, no fever, no sensory loss, normal CSF
-treat by searching the tick and remove it!!!

)In Down' s syndrome-on US there's increased nuchal thickness

)Informed consent can be revokwed any time by the patient=>withhold the procedure!!!

)Frozen shoulder-restricted range of motions in all directions, both apssive and active due to pericapsulitis
-treat by NSAID, intraartic. corticosteroids, physical therapy

Rotator cuff tendinitis or tear-tell them apart by lidocaine injection; it will clear the pain in tendinitis

Supracapsular neuropathy-weakness on abduction and external rotation
-atrophy of the supra/infraspinous muscles

)DM symmetrical neuropathy=>earliest finding=loss of viratory sense
MC CN involved=III
MC peripheral nerve involved=median

)If pyelonephritis does not respond to antibiotics in 3 days (still feverish)=>get renal US to rule out obstruction/abcess/complications

)To all newly diagnosed HIV patients this should be done:
-routine chemistry and hematology
-2 plasma HIV-RNA titers
-CD4 count
-VDRL
-PPD skin test
-anti-toxoplasma antib. titer
-mini mental status examination
-hep.A, B serology
-hepA, B vaccine if serology is (-)
-pneumococcal vaccine if CD4>200/ul

Before starting anti-retroviral treat, do:
-hystory+physical exam
-CBC, chemstry, LFT, lipid profile
-CD34 count
-a plasma HIV-RNA titer

)Hyeprdense areas on CT=Hemorrhage
Hypodens areas=infarcts

)HIGH-YIELD
Pregnancy protects against PUD and multiple sclerosis (MS)

)PEEP complications=tension pneumotorax, alveolar damage, ventricular failure

)Cellulitis-diffuse infection of deep skin layers
-fever, inflam. signs, no crepitus or bullae
-lymphangitis
-overlying skin necrosis
-toe web tinea pedis=gate for cellulitis

Necrotizing fasciitis-deep cellulitis
-overlying skin necrosis, bullae, crepitus, fever
-anesthesia due to nerve damage

Sclerosing panniculitis-acute tender lesion over the medial meleolus
-in venous stasis of the limb
Erysipeloid-purplish plaque with central clearing
-no fever, not very painful
-on hands of fishermen and meat handlers

)Osteomalacia-x-ray: symetrical looser zones, pseudofractures bilaterally with blurring of the spine=characteristic
-low Ca, P, high PTH

)Genralized resistance to thyroid hormons=>hypothyroid features despite high T4, T3, high to normal TSH
)Fibromuscular dysplasia of renal artery-children, women<50 years
-on angiogram: "string of beads"
-diastolic HTN

)Mass in the epigastrium 4 weeks after acute pancreatitis=>think pseudocyst; drain if over 6 weeks and >5cm large

)Leprosy-affects peripheral nerves, skin
-hypopigmented patch of insensate skin
-muscle atrophy due to nerve damage (patchy and segmental)
-diagnose by skin biopsy
-patient came from Asia

) Hyperthofic osteoarthropathy=chronic proliferating periostitis of long bones, clubbing of fingers, synovitis
-associated with SCC and adenocarcinoma of the lung
REMEMBER!!!Any chronic smoker with this disease should have a CXR done to rule out lung cancer!!!

)Atrial flutter-unstable=>cardiovertion 50-100J
-stable-either cardioversion with ibutilide (in acute cases) or rate control with beta and Ca channel blockers (in chronic cases)

)Turocut's syndrome-brain tumors+fam. adenomatous polyposis or HNPCC
Multiple mamartoma syndrome (Cowden's syndrome)=GI tract hamartoma+breast cancer, thyroid cancer, nodular gingival hyperplasia
Cronkite-Canada syndrome=juvenile-type polyps+alopecia, hyperpigmentation, nail loss

)In stroke-treat HTN if only>220/130mmHg
-reduce it gradually over several hours
-use nicardipine or ACE inhibitors

Use iv. steroids-in trauma (head injury)
-in tumor induced cerebral edema
-use tPa in 3h after the onset of stroke

)Beta-2 agonists-give higher systolic and lower diastolic pressure, tahicardia, fluid retention, hyperglicemia (stimulates gluconeogenesis)=>increases insulin requirements in DM patients
-gives low K
-edema, increased myocardial work

)Berylliosis=granulomatous lung disease
-high teck industry (aerospace, ceramics,electronics)

)In MVA patients=>rule out cervical injury by X-ray of the neck or CT or head+neck


)Barrter's syndrome-normal BP
-low K, metabolic alkalosis
-high renin, high aldo
-high urinary Cl

)BPH-treat with alpha-blockers or finasteride
Finasteride-effective in BPH with epithelial predominance
Alpha-blockers-for muscle predominance
Collagen predominance-doesn't respond to either of them

)Megaloblastic anemia-high MCV, MCH, normal=MCHC
)If asymptomatic elevation of AST/ALT in anti-TB treatment=>continue treatment because they return to normal later in most patients
)Antibodies to Borellia burgdorferi=>cross-react with Treponema pallidum

)Vaginismus-treat by relaxation, Kegel exercises, gradual dilatation
-refer to sex-therapist only in case of hypoactive-sexual desire

)MCC of death in order:
-before 1 month of age: -cong.anomalies
-low birth weight
-SIDS
-between 1month-1year of age:-SIDS
-congenital anomalies

)In panick attacks, next step in treatment=benzodiazepine; then for long-term=SSRI

)Pneumonia+diarrhea+hypo Na=>think Legionella

)Scleroderma-anti SCL70, ANA
Sjogren syndrome-anti SS-A, anti SS-B
Polymyositis/dermatomyositis-ANA, anti Jo 1
SLE-ANA, RF, anti-Smith,...

)MVP-gives IE prophylaxis if murmur heard
-give beta-blockers for palpitations, chest pain...

)Hyperthyroid=>higher systolic BP
Hypothyroid=>higher diastolic BP

)To see if thre's statistical association between HRT therapy and CRP levels=>use Chi-square test; it compares proportions of categorized outcome. The expected values are compaired with the observed values; if there's no difference=> no statistical significance

)Angioedema=non-inflamatory edema of face, limbs, genitalia, laryngeal, bowels; high levels of C2B and bradikinin

)Hepatic encephalopathy-due to NH3=>metabolic alkalosis

)MCC of death in dialysed patients=from CV disease; the same in renal transplanted patients

)In hepatic failure-if active bleeding=>give FFP
if only high PT and PTT=>give vit.K 3 days

)Hydatid cyst-do not aspire (risk of anaphilaxis); treat by surgery with metronidazole cover

)Bacterial vaginosis in pregnancy-give clindamycin cream or metronidazole cream, not oral metro because of teratogenity in Ist trimester

)Iron poisoning-GI upsets, resp alkalosis+metab. acidosis, hypoTN, X-ray: tablets in the stomach
-treat-asymptomatic: ipeca
-moderate-severe intox.:deferoxamine; NOT Charcoal

)PTSD-associated with substance abuse=>avoid benzodiazepine in these patients
-treat by SSRI+exposure therapy

)Reiter syndrome-due to Chlamydia, but also from diarrhea from Salmo, Shige,Campilo
-entesopathy(heel pain+saussage digits)
-polyarthralgias
-treat by NSAID +tetracycline

)Dissection of thoracic aorta with high BP(>200/115mmHg)=>give Nitroprusside+short acting beta-blocker

)Generalizability=external validity of a test-answers the question how generalizable are the results of a study on a certain population (middle-aged males) to the rest of the population

)Hahimoto's thyroiditis-anti-peroxidase antibodies

)In acute ulcerative colitis (even toxic megacolon)=>can do proctosigmoidoscopy with biopsy for the diagnosis
-NOT CT

)Fibromuscular dysplasia-treat by angioplasty=CHOICE

)In women with high risk of breast cancer=>give prophylactic tamoxifen

)Porcelain gall-bladder-diagnose it entirely on X-ray of abdomen=>resect it because of risk of carcinoma

)CT scan in Alzheimer: diffuse cortical&subcortical atrophy

)Premenop.women with intermitent menstrual bleeding, heavy menses=>endometrial biopsy
-if complex hyperplasia without atypia=>give cyclic progestins and repeat biopsy 3-6 months later
-if complex with atypia=>cyclic progestins (if she wants fertility)+3-6 months biopsy; if no fertility desired=>hysterectomy

)Neonatal tetanus-generalized, born from unimmunized mothers, infection of umbilical stump in poor obstetrics

)Systemic sclerosis=>gives interstitial fibrosis (40%) and pulmonary HTN (10%)

)Arthritis=late manif. of Lyme disease
-intermitent attacks are typical (months after exposure)

)Ant. dislocation of shoulder=>injury to the axillary nerve

)HIGH YIELD Syncope from arrythmia:
-heart disease
-ectopic beats
-hydrochlorothiazide

)Pulmonary edema in infero-lateral MI=>give diuretics, NOT beta-blockers

)Parkinson disease-(+) Meyerson sign
-associated with seborrheic dermatitis-this is associated with HIV too or acutely ill patients!!!!

)MC acid-base disorder in U.S hospitals=metabolic alkalosis

)In DKA-monitor recovery by PH and serum AG

)HIV and heroin addicts=>associated with focal segmental glomerulosclerosis

)Acute vaso-oclussive crisis(priapism,stroke, severe pain) in HbSS=>exchange transfusion

)Caroli's syndrome-associated with adult PKD
-risk of 100 times of cholangiocarcinoma

)Stable angina+HTN=>gibe beta blockers; if c.i. give Ca channe blockers
)In children, aspirin toxicity gives metab acidosis+resp. compensation
In adults, it gives primary metab.acidosis+primary resp.alkalosis

)MC side effect of radioactive thrapy for Graves is hypothyroidism!!! HIGH YIELD; also exacerbates ophtalmopathy

)Acute interstitial nephritis-fever, rash and peripheral eosinophilia in an azotemic patient
-(+) Hansel stain-for eosinophiluria
-type 4 hypersensitivity reaction

)If suspect SCC=>do punch biopsy
-treat by surgery with wide excision; alsoradiotherapy could reduce its size

)Cryptococcal meningitis-by India Ink
-treat by: iv amphotericin B +oral flucytosine; then when improves give oral fluconazole-give it from the beginning if asymptomatic

)PID-treat by: cefotetan/cefoxitin+doxi or clinda+genta

)Asthma+allergic rhinitis or eczema=>drug of choice=mast cell stabilizers (chromolyn)

)Subacromial bursitis-from impingement syndrome by prolonged overhead activity (tennis, golf, swimming)
-shoulder pain on overhead activity, absent on rest
-Neer's sign of impingement=pain on passive internal rotation and forward flexion at shoulder
-confirm by US or MRI, X-ray is normal
-treat by NSAID, physical therapy

)Urethral injury-triad:
-blood at the meatus
-inability to void
-destended bladder

High riding prostate+scrotal hematoma=post. urethral injury

)Heat stroke-may progress to DIC
-is due to failure of the thermoreglatory center
-t>105F, CNS symptoms

Uncontrolled Ca release=malignant hyperthermia
Fever-by citokine activation

)Miliaria-in people living in moist and hot climates
=heatr rash

)Addison's disease=low Aldo=>non-anion gap metab. acidosis

)Primary adrenal insufficiency=>high ACTH=>hyperpigmentation
Secondary............................=>low ACTH=>nohyperpigmentation

)In BPH=> first do urinalysis+serum creatinine, only after US or IVP in case of complications (hematuria, UTI...)

)Human bites-prophylaxis with Amoxi-Clavulanate

)Lacunar infarcts-from HTN-remember dysarthria-clumsy hand syndrome
-limited neurologic deficit

)Whipple disease-diarrhea,arthralgias, weight loss, fever, chills, hyperpigmentation, valvular regurgitation, migratory lymphadenopathy
-PAS (+) deposits in the lamina propria+villous atrophy

IBD-has migratory polyarthritis, erythema nodosum,(+) p-ANCA

)Galactogram guided resection=treatment of choice for intraductal papilloma!!!

)Mutations-severe: frameshift or nonsense mutation
-milder: missense or splice-site mutaion
-silent: same sense mutation
)Thiazide effects: low Na, low K, high Ca, hyperglicemia, high TG, high LDL

)Ibuprofen raisis Li levels, so if a patient is on both medications=>can worsen psoriasis beacuse of high Li levels

)Screen for DM: fasting blood glucose
-in getationalm DM-use 50 g glucose tolerance test for screening and 100g for confirmation
-use 75 g for confirmating non-gestastional DM

)Steatorrhea-gold standard=3-5 days of fecal fat collection

)Non -alcoholic hepatic steatosis-risk factors:
-obezity
-DM
-TPN
-hyperlipidemia
-amiodarone
-bypass surgery for obezity
On biopsy, it looks like alcoholic steathosis
-treat by ursodeoxycolic acid

)Complex partial seizures-brief episodem of impaired consciuosness, automatisms (lip-smaking, swallowing, picking with hands...), followed by post-ictal state, EEG=normal; hyperventilation does not produce a seizure

Juvenile myoclonic epilepsy-starts in adolescents
-unilat/bilat. myoclonic jerks
-appear in the morning, precipitated by sleep deprivation

Atypical absence seizure-last longer than typical and EEG shows slow-spike and wave activity<2.5Hz

)Male infertility=>do sperm count=>endocrine evaluation (testosteron, FSH, LH, prolactin)

)Marfan's features+thromboembolic events=>think of classic homocystinuria
-RA disease
-normal at birth
-in infancy=failure to thrive
-ectopia lentis (downwards here, as compared to upwards in Marfan's syndrome), cataract
-fair skin, hair, blue eyes=>like in PKU
-high homocysteine, high Met confirm the diagnosis
-treat by high doses of Vit B6; can give also cysteine

Fabry disease=deficiency of alpha-galactosidase
-angiokeratoma, peripheral neurophathy
-asymptomatic cornea dystrophy
-thromboembolic events

)Aortic regurgitation-rapidly raising carotid pulse+sudden collapse=Water-Hammer pulse
-3rd intercostal space diastolic murmur, intensified by Valsalva!!!

)Parathyroid adenoma, even asymptomatic=> do parathyroidectomy

)Metastatic osteolysis-normal P, high ALP

)Amebic abcess-hystory of travel (Mexico), followed by bloody diarrhea, then RUQ pain because of cyst in the liver
-treat by metronidazole

)Ulcerative esophagitis in HIV patients-due to CMV
-large, shallow superficial ulceration+intracellular inclusions
HSV esophagitis-multiple, well circumscribed, small deep ulcers (like volcanos)
Aphtous ulcer-giant ulcer on the esophag, treat by prednisolone

)If on MAO inhibitors=> don't give SSRI, meperidine, pseudoephedrine

)If swalloed battery in the esophagus=>remove immediately (not by emesis)
)Post-op pulmonary edema=>think overhydration
-high central venous pressure (CVP)
-S3 gallop
-high diuresis >2.5l/day
-high BP
Must rule out MI first!!!
)MC thyroid nodule=hyperplastic colloid nodule=>followed by follicular adenoma

)Bilroth II=> can be followed by bacterial overgrowth with malabsortion

)Young black male with painless hematuria=sickle-cell trait

)Complications of chronic hep. C:
-cryoglobulinemia, GN
-B-cell lymphoma
-plasmocytomas
-autoimmune disease (Sjogren, thyroiditis)
-lichen planus
-ITP
-porphiria cutanea tarda

)Testicular feminization syndrome
-testicles produce MIF (Mullerian inhibiting factor)=>no uterus, vagina, tubes
-breasts develop because of peripheral production of estrogens
-no pubic/axillary hair

)Galactose-1P-urydil transferase deficiency=>shock, low IQ, vomiting, diarrhea, hepatomegaly, cataract, hyperglicemia

Galactokinase deficiency-milder form, only cataract if untreated

)ECT-indications:
-severe depression/mania, also in pregnancy
-neuroleptic malignant syndrome
-catatonia
Side effects: apnea, amnesia, seizures, muscle soreness, headaches, status epilepticus, skin burns, delirium

)Cystic fibrosis-brochiectasis (upper lobes)-tram track lines on CXR
Gold standard=sweat chloride test, prefered over DNA mutation indetification

)Hemodialysis on citrate=>metabolic alkalosis
-also from infusion of more than 8 units of banked blood

)Cat-scratch disease-B. Henselae
developsin 3-10 days after scratch or bite
-papular/vesicular lesion+proximal adenopathy

Pasteurella Multocida- cat/dog bite
-intense inflamatory reaction in 24 h
-purulent discharge

)Ant. cerebral artery stroke=>controlat. sensory/motor paresis more prominent in the lower limbs, urinary incontinence, gait apraxia, abulia, primitive reflexes

)Purpura Henoch-Schonlein=> can cause intussusception (ileo-ileal=>get surgery to resolve it)

)Introjection=absorbing aspect of another person into one's own self-image; ex. a victim of abuse absorbs her father's iamge about her as "stupid" and defends his father's need to abuse her!!!

)If suspect PE, do X-ray, EKC, ABG to rule out other diseases=>then give heparin without waiting for V/Q scan to confirm it; you'll do it finally, but treatment is more important first!!!

)ARDS-has:
-PaO2/FiO2<200
-PCWP<18mmHg
-diffuse alveolar infiltrates, prominent air bronhograms

)DM cystopathy (overflow incontinence)-treat by:
-strict voluntary urinary scheduling+oral bethanecol
-intermitent catheterisations in advanced cases
-internal sphincter resection at the bladder neck in severe cases
)Esopahgeal cancer-may looklike achalasia,but:
-duration of sysmptoms is short (months)
-wieght loss is profound
-elderly, smoking hystory
-inability to pass a tube through LES

)Amyloidosis-hystory of RA
-enlarged kidneys and liver
-biopsy of kidney: apple-green birefringence under polarized light after staining with Congo red

)Asymptomatic gall-stones=>do not treat

)Lymphogranuloma venereum-if untreated can give proctocolitis, rectal stricture, recto-vaginal fistulas, elephantiasis

)Toxoplasmosis-in pregnancy:
-Ist trimester=>give spiramycin or elective terminationof prenancy
-IInd or IIIrd trimester=>give perimetamine+sulfadiazine; also give folic acid

)Aspergillosis-in worsening asthma, coughing brownish mucous plugs, reccurent infiltrates, peripheral eosinophilia

)Mediastinitis-post CABG complication
-systemic signs, wide mediastinum on CXR
-treat by thoracotomy for debridement, drainage and antibiotic therapy

Post-pericardiotomy syndrome-systemic inflamatory signs, small amount of pericardial fluid that does not cause a wide mediastinum

)High risk IE: -prosthetic valves
-hystory of IE
-cyanotic heart disease of surgically constructed systemic-pulmonary shunts
Moderate risk IE:-PDA, VSD,osteum primum ASD, coarctation, aortic bicuspidy, MVP with regurgitation, HCM

If one of these patients get an upper GI endoscopy (low risk procedure)=>prophylaxis is optional in high risk group and not recommended in the rest of the population
Generally give prophylaxis for bleeding procedures (but not cesarian or vaginal delivery) in both groups!!!

)Unexplained HTN+low K levels=>measure Aldo+renine levels, then do Aldo suppression test to confirm primary Aldosteronism=>CT scan of the adrenal to locate the tumor=>if no mass on CT, do adrenal vein sampling

)Reye's syndrome=extensive fatty vacuolization of the liver
Alcoholic hepatitis=balloon degeneration with PMN infiltrates

)If travelling to SE Asia (zone with highly resistant to chloroquine malaria)=>give mefloquine for prophylaxis
Use Fansidar=>only for treatment after the occurence of symptoms
Use Primaquine for P. vivax and ovale

)Slipped-capital femoral epiphysis-X-ray of choice for diagnosis is frog-leg lateral view
-treat by surgery (external fixation the joint with screws)

)Pericardial cyst-in the middle mediastinum
-aspirate fluid for treatment (not surgery)

)Impaired ADH secretion=>occurs in alomost all patients with Sheehan's syndrome=>differentiate from lymphocytic thyroiditis HIGH-YIELD

)To prevent hep. B infection after liver transplant in a chronic hep. B patient=>give Hep.B IG+lamivudine

)Analgezic nephropathy-papillary necrosis or tubulo-interstitial nephritis
-polyuria+sterile pyuria=early manifestations

)In refractory cirrhotic hydrotorax=> do TIPS=CHOICE
Use pleurodesisw in refractory effusions from malignancies, not cirrhosis


)Ovarian hyperstimulation syndrome
-5-7 days after hCG or hMG administration
-abdom. pain, distension, dullness to percusion, weight gain, pleural effusions, low BP
-complications: ovarian torsion, multiple gestation, ovarian rupture, trombophlebitis

)<3 tetanus immunizations:
-clean wound=>give Tetanus toxoid (TT)
-dirty wound=>give TT+ TIG
>3immunizations:
-clean wound=>give TT if last immunization>10years ago
-dirty wound=>give TT if ..........................>5 years ago

)Prolonged central venous lines for TPN=> can give subclavian vein thrombosis

)Diastolic dysfunction of LV secondary to hypertrophic cardiomyopathy from HTN=>give Beta-blockers=CHOICE, if fail add Ca channel blockers

)Prolactinoma-asymptomatic=>follow with MRI and serum prolactin
-symptomatic microadenoma (amenorrhea, galactorrhea)=>give dopamine agonists (bromocritine or cabergoline); also add estrogens because of risk of osteoporosis due to hypoestrogenism
-if not responding to drugs or impaired vision=>do surgery
-use radiotherapy for aggressive tumors that do not respond to surgery

)Reccurent pancreatitis with no obvious cause (no alcohol, no gall-stones)=>do ERCP to look for microlithiasis, choledocal cyst, pancreatic divisum

)IE-no arthralgias (this would be rheumatic fever)
-can have microscopic hematuria
-do blood cultures and give antibiotics immediately
-then do TEE to confirm it

)Impaired consciousness, even following a first seizure=>do CT scan without contrast
-not EEG

)Pneumonia that does not respond to beta-lactamines=>suspect Legionella
-diagnose by urinary Legionella antigen (ELISA)

)Rotator cuff injury-diagnose by MRI
-does not respond to lidocaine injection as tendinitis does

)Ant. urethral injury=>immediate surgical repair
Post. urethral injury=> voiding cystourethrogram

)Hep. C-moderate: IFN+ribavirin
-mild: IFN

)Raloxifene=>increases risk of thromboembolism
-c.i. in DVT

)Tardive diskynesia: 4 months-4 years
-switch to clozapine

)HIGH-YIELD
In asthma, after iv glucocorticoids can give neutrophilia by mobilizing the neutrophile pool; also lower Eo and lymphocytes

)Fibromyalgia=>give TCA for treatment or cyclobenzaprine
-trigger point injections

)Pericardial tamponade=>has electrical alternans (alternating amplitudes of QRS)

)When suspect Addison' s disease=> do ACTH (cosytropin) stimulation test to make the diagnosis
-get plasma ACTH to distinguish between primary or secondary Addison, oce the diagnose is made!!!

)Patients with cirrhosis shouldhave endoscopy to be screened for esophageal varices=>prophylactic beta-blockers
)Ehrlichiosis=called spotless RMSF
-no rash
-incubation=1-3 weeks
-anemia, low Le, low T
-increase in AST/ALT
-treat by Doxi or Chloramfenicol

)Lung cancer=>think of paraneoplstic syndrome=>muslce strengh diminuished bilaterally, more proximal than distal
-normal reflexes
-increase in CK, (+) EMG
-pathology is located in the muscle membrane!!! Strange this topic, I don't know why either, but this is what they say!!!

)Foreign body aspiration=sudden onset of resp. distress, afebrile, interstitial retractions
-do direct laryngoscopy+rigid brochoscopy
-one lung is hyperinflated, the other is hypoinflated
)Bronchiectasis=>can have life-threatening hemoptysis
Disseminated gonococcal infection-rash, tenosynovitis, polyarthralgia (migratory)
-mediated by immune complexes from gonococcemia!!!

)Venous ulcers=>medial aspect of foot
Arterial ulcers=>lateral........................

)If isolated proteinuria detected=>repeat distick testing at least twice more; then if still (-)=>reassurance; if (+)=>check 24h urinary proteins, BUN, Cr

)Salmonella=MCCof osteomyelitis in HbSS disease (not Staph as many say)---there's much controversy about this issue!!!

)Dipyridamole=>gives coronary steal when used in heart stress tolerance testing

)Asymptomatic Paget disease=>no treatment
-symptomatic (lytic lesions or skullinvolvement)=>biphosphonates=CHOICE

)Iron def. anemia in males or post-menop.female is MC from GI blood loss!!!

)Pneumonia post bone marrow transplant=>think CMV
-not immediate, comes in about 2 weeks to 2 years post-transplant

)Cerebral wasting syndrome=>in patients with SAH because of innapropriate secretion of ADH, increased secretion of BNP=>low Na+water retention
-it clears in 1-2 weeks

)Marfan's syndrome=>AD disease, mutation of fibrillin-1 gene
-also has iridodonesis, ectasia of dura

)To detect the benefit of lung resection=>do PFT, especially FEV1

)Brown recluse spider-deep bite, ulcer with a necrotic center and erythematous halo, treat by local excision
Black widow spider=>abdominal rigidity, muscle cramps, nausea, vomitting, no local ulcer
-treat by Ca gluconate, muscle relaxants

)In pheocromocitoma=>if use beta-blockers first, before alpha=>rapidrise in BP, so first use alpha, than beta blockers!!!

)Screening for prostate cancer:
->40 years=yearly rectal exam
->50 years=PSA=rectal exam
-if abnormal=>transrectal US, then niddle biopsy, then bone scan for staging

)Status epilepticus=> treat by general anesthesia+intubation!!!
)In epiglotitis=>endotraheal intubation+preparations for a traheostomy, then antibiotics (ceftriaxone)


)Intelectualization=transforming an unpleasant event into a purely intellectual problem
Rationalization=offering rational explanations in an attempt to justify undesirable attitudes, impulses, beliefs-ex. a guy is rejected from getting jobs at various interviews says that he saved money because the commute was paid by his interogators...

)Choriocarcinoma:post-partum, women with dyspnea, hemoptysis
-CXR: multiple infiltrates, high Le, anemia
-enlarged uterus, vaginal bleeding
-so pulmonary and genital symptoms present
-do quantitative beta hCG first to confirm the diagnosis!!!

)Solid testicular mass, painless+suggestive US=>first do inguinal orhiectomy
In testicular caner, first we kill the tumor, then we investigate. NEVER DO BIOPSY=>risk of metastasis

)If uncomplicated pyelonephritis responds to iv. antibiotics=>can switch to oral ones in 48-72h based on antibiogram

)Internuclear ophtalmoplegia=demyelinization of medial longit. fasciculus
-sign of MS

)Cervical spondylosis-chronic neck pain, limited rotation and lateral bending of head
-sensory deficit due to osteophyte-induced radiculopathy

)Atrial myxoma=>systemic signs, dyspnea, like mitral stenosis, but no opening snap, murmur changes with position=>high risk of embolization

)Low Ca, high P, high PTH=secondary hyperPTH due to renal failure
-lung cancer: high PTH-related peptide, high Ca, low P
-primary hyper PTH: high Ca, low P, high PTH
-multiple mieloma: high Ca, low to normal PTH

)Hairy-cell leukemia: B-cell leukemia
-tartrate resistant acid phosphatase
-give cladribine for treatment!!!

)HIV patient pneumonia-MC is still pneumococcus
In PCPpneumonia=>no pleural effusions

)Eaton-Lamber Syndrome=>auto-antib. against gated Ca channels
-small-celllung cancer
-treat by plasmapheresis+immunossupressive therapy

)To diagnose lutheal phase defect=>endometrial biopsy which shows loss of endometrial maturation by more than 2 days as compared to normal

)MVP=MCC of mitral insufficiency in the U.S.

)CD<50/ul=> do prophylaxis for mIcobacterium intracellulare with azytromycin or claritromycin; alternative: rifabutin

)In cerebellar hemorrhage=>do emergent cerebellar decompresion

)Schizoaffective disorder=>schizofrenia is present even in the absence of modd disorders, but not visa-versa!!!

)To improve oxygenation in ARDS=>give PEEP

)In SLE, the most severe form of GN is also the MC= diffuse prolipherative

)To diagnose inhalation injury=> do brochoscopy and Xe retention studies for the terminal respiratory tree

)Risk factors in order for DM foot ulcers:
a)neuropathy
b)peripheral vascular disease
c)glicemic control
d)abnormal structure of the foot
e)other:smoking, male sex, DM with a duration>10 years

)Solitary brain metastasis=>surgical resection, followed by whole brain irradiation
Multiple brain metastasis=>palliative brain irradiation

)Acute livwer failure-appears within 8 weeks from the start of the injury
Fulminant hepatitis=acute liver failure+hepatic encephalopathy
)In neurofibromatosis type 2, when suspect acoustic neuroma=> first do MRI with gadolinium=best test, then surgery to remove the tumor

)Kallmann's syndrome-46,XX
-anosmia
-hypogonadotropic hypogonadism
-absent pubic, axillary hair
-absent breasts
-amenorrhea

)Displaced ant. fad pad=X-ray sign of supracondylar fracture which may be complicated by Volkmann's ischemic contracture

)Patient of IPPV who deteriorates=>do CXR to rule out barotrauma

)In SLE=> non-erosive arthritis
In RA=erosive arthritis

)Afetr abdom. aortic aneurysm repair and blood in the stool=>suspect ischemic colitis=> do sigmoidoscopy/colonoscopy to assess coloniv viability, if CT scan is inconclusive, BUT NOT Barium enema=>can cause perforation

)Metabolic X Syndrome: central-type obesity
-insulin resistance

)OCP in chronic users=>cholestatic liver disease

)Malaria-P.vivax-fever every 48h
P.ovale-fever every 72h
P. falciparum=>no periodicity
-starts with intens chills, then the hot phase, then 2-6h later-vomitting, low BP, tahicardia
-anemia, splenomegaly
-hystory of past similar complaints when in Africa

)Babesiosis-RBC cell parasite
-from ticks
-varies frrom asymptomatic to severe anemia, jaundice and renal failure
-seen in splenectomised patients or with HbSS diseases

)Polyneuropathy in DM=best diagnostic tests are: EMG+conduction studies, not evoked potentials!!!

)If pregnant minor doesn't want ot tell her parents about the preganancy=> encourage her not to tell!!! (patient's right to confidentiality)

)TB can appear in HIV patients even with CD4>200/ul
-no need of hystory of close contacts

)CHF due to aortic regurgitation=>give diuretics, ACE inhibitors, digoxin, NOT Beta-blockers-which prolong the diastole=>increased regurgitation

)Gall-stones-mostly of cholesterol
-in obese patients
-in pregnancy
-clorfibrate therapy
-more in Western than in Asian populations

)Diarrhea in HIV patients=> first do stool examination to determine the bacteria responsable for this
-usually is determined by bacteria rather than by previous antibiotics intake, son don't stop TMP/SMX, Claritromycin...


)In amenorrhea=> determine estrogen status (endogenous estrogen production) by a challange test; however this has been lately abandonned and replaced by:
-cervical mucus analysis
-vaginal epithelial maturation
-endometrial thickness

)Asthma not controlled by medication with a silent chest, even with a 90% O2 saturation=>intubate+mechanical ventilation
-DON'T GIVE thophiline in status asmaticus

)Dressler's syndrome-2-4 weeks post-MI
-pericardial effusion, diffuse ST elevation
-treat by NSAID, or if they fail, give steroids

)DM with erectile dysfunction=>first choice is Sildenafil (Viagra) and NOT:
-local PG (alprostadil)
-tighter glicemic control
If combined with an alpha-blocker=>give them at least 4h apart to prevent hypotension

)PCP pneumonia in HIV patients-bilat. interstitial pneumonia
-think of it even if the patient is on steroids, even there's no fever, even if there's blood in the sputum and asymetry of infiltrates; second choice=TB

)Pseudotumor cerebri-medical treatment: acetazolamide=first line, then steroids or repeated lumbar punctures
-surgical treatment: optic sheath decompression+lumboperitoneal shunting

)HIGH-YIELD
Osteogenesis imperfecta-mutations of collagen type 1 gene
-blue sclerae, reccurent fractures
-hearing loss

)Rib fractures=>prime priority=appropriate analgesia
-mechanical stability=>not required with a single rib fracture, only in flail chest

)HIGH-YIELD
Insipidus diabetes-polyuria, polydipsia, patients prefer cold beverages because they quench their thrist better
-Serum Osm>Urine Osm
Primary polydipsia, low both serum and urinary Osm
Osmotic diuresis-Urinary Osm>Serum Osm
SIADH-low serum Na, Urine Osm>Serum Osm

)Think of sphincter ODDI dysfinction post-cholecystectomy=>do ERCP with sphincterotomy

)Lutheal phase defect-treat with progesterone vaginal suppositories; first confirm with endometrial biopsy
-if suppositories don't work, try clomiphene or hMG

)In taking antidepressants=> monitor therapy at least 4-6 weeks before changing to another one

)When suspect DVT=>do compression US, then give anticoagulation; this is not a clinical diagnosis and you need a confirmatory test. If there was a similar question about pulmonary embolism (PE), you would have started anticoagulation first, followed later by V/Q scan!!!!! REMEMBER THIS!!!
Use impedance pletismography=>for recurent DVT

)Total knee replacement-do it in patients with severe restriction of walking or nocturnal and rest pain

)In trauma patients with collapsed veins in order to give iv. fluids=> do saphenous vein cutdown or percutaneous femoral vein catheterisation
-DON'T USE subclavian or jugular veins!!!
In children <4 years of age=> do interosseous canullation

)Ca channel blockers=> can give peripheral edema

)CT scan-is not diagnostic of pheocromocitoma, but hormone levels are!!!

)Ursodeoxycolic acid=>disolve radioluscent stones<1cm in 50% of patients in 6-12 months of therapy
)Hystory of iv. drug abuse+high fever+bony point tenderness, redness, pain, swelling=>suspect osteomyelitis=>get Tc scan, MRI=>good for vertebral osteomyelitis

)In pseudodementia-CT is normal
-dexamethasone suppression test in abnormal in 50% of patients
-there's a trigger event
Tourette's disorder-associated with ADHD(60%) and OCD (27%) HIGH YIELD -I got many questions on my actual exam!!!!!

)Acute inflamatory arthritis superimposed on osteoarthritis=>septic arthritis
)Intimal flap injury of the carotid artery=>do surgery to repair it, because it can lead to vessel occlusion

)Myocarditis-MCC=Coxsackie's B virus
-dilated cardiomyopathy, after a "flu" 4 weeks earlier
-raise in CK, CK-MB

)To detect microalbuminuria in DM=> do urine collection over 24h or more convenient check random albumin/creatinine ratio. If =30-300mg albumin/mg creatinine=>microalbuminuria
Protein dipstick is (+) only for >300mg/day proteinuria

)Essential tremor=>give beta-blockers=first line; also primidone, BUT PRIMIDONE converts into feniletilmalonamide+phenobarbital=> can give acute intermitent porphiria-diagnose it by urinary porphobillinogen

)In Candida infections=> do not treat partners

)Stranger anxiety: 12-15 months of age
Separation anxiety: older child

)Narcolepsy-treat by day-time scheduled naps, psychostimulants+antidepressants (if cataplexy present)

)Extrinsic allergic alveolitis-Farmer's lung, bird breader's lung
-type III reaction
-CXR: bilat.interstitial infiltrates, PFT: restrictive pattern
-treat by avoiding exposure

Alveolar proteinosis-phospholipid-rich material in the alveoli due to impaired clearance
-restrcitive pattern
-bilat. interstitial infiltrates
-lung biopsy: PAS(+) material
-treat by broncho-alveolar lavage

)Post-cholecystectomy pain-causes:
-sphincter Oddi dysfunction
-CBD stone
-functional pain-think of this only if LFT are normal, no biliary tree dilation
If biliary tree is dilated and high ALP=>check to rule out stone
and if no stone=> do biliary manometry to detect sphincter Oddi dysfunction

)Nocardiosis-pulmonary disease
-in imunocompromized patients
-CNS manifestations
-cutaneous manifestations
-onset is subacute (days to weeks)
-abcess formation in the lung
-crooked branching beaded gram (+) filaments, weakly acid-fast (+)
-treat by TMP/SMX or Minocycline
-prophylaxis: TMP/SMX

)Guillane-barre syndrome-causes:
-Campilobacter
-herpes viruses
-mycoplasma
-H. influenzae
-recent HIV infection
-recent immunisation
)If suspicious of PR=> do V/Q scan; if inconclusive do limb venous US or CT angiogramof the chest; if both are (-)=> do pulmonary angiography

)In SLE, anti-Ds DNA antibodies=> correlate with disease activity of nephritis
Anti-Ro-associated with neonatal lupus, cong. heart block, interstitial lung disease, fotosensitivity

)Nasopharingeal cancer-MC presenting symptom is painless neck mass!!!

)OCP-potential cause of HTN=>first measure is to discontinue them, if still HTN=> do lifestyle modifications, then try low dose thiazidic is these fail

)Metastatic solid tumors=>hyper Ca by citokines (IL-1, TNF)
Hodgkin's disease-hyper Ca by calcitriol production
Non-metastatic solid tumors-hyper a by PTH-related Peptide

)Complications of ERCP:
-pancreatitis
-biliary enteric fistula after sphincterotomy
-biliary peritonitis
-sepsis
-hemorrhage
Note: AIR in the billiary tree after ERCP is NOT normal!!!

)Sumatriptan-c.i. in:
-uncontrolled HTN
-basillar migraine
-CAD
-Prinzmetal angina
-ischemic stroke
-pregnancy
-familial hemiplegic migraine

)Vesico-ureteral reflux in children can lead to renal scarring!!!

)Malignancy of a solitary nodule:->3cm
-irregular borders
-eccentric calcifications

)MCCof asymptomatic elevation of ALP in the elderly is
Paget disease
Simvastatin-increases AST/ALT and not ALP

)Ligament injury=>get MRI of the knee, if inconclusive do arthroscopy

)In aortic dissection with HTN=> first give anti-HTN medication, then do TEE

)Infectious mononucleosis-heterophile antibody test is very specific, so a (-) test does not exclude the disease!!!

)Ascites-management:
-first: diagnostic paracentesis
-then: salt restrction diet (0.8-1g/day)
-then: spironolactone=directic of CHOICE in ascites
-then if still uncontrolled: add thiazides or loop diuretics
-if refractory: do TIPS

)Strep. pneumoniae=MCC of pneumonia in nursing home patients=HIGH YIELD

)Herpes encephalitis-CSF:lymphocytosis, high erytrocytes too, high protein, normal glucose, high opening pressure
-acute onset<1 week
-focal neurological findings (seizures...)-temporal lobe
-CT scan ca be normal in 50% of patients (SO THINK OF THIS DISEASE EVEN IF CT IS (-))
-fever
In Cryptococcal meningitis, there's low glucose, but the rest can look the same as in herpes


)In utero exposure to phenitoin=>risk of neuroblastoma
Hydantoin syndrome: nail hypoplasia, microcephaly, cleft-lip, hypoplasia of the distalphalanx, cardiac problems

)Type I Collagen storage disease (von Gierke)
-deficiency of G-6P phosphatase
-hepatomegaly, enlarged kidneys, hypoglicemic seizures
-doll-like face with fat cheeks
-short stature, protuberant abdomen
-low glucose, high TG, high lactic acid, high total cholesterol, high uric acid, normal AST/ALT
Type II-Pompe-def. of glycogen storage enzyme=maltase
-first weeks of life with floppy baby, macroglosia, hepatomegaly, heart failure, HCM
Type III-def. of glycogen debraching enzyme:
-high AST/ALT, fasting ketosis
-normal uric acid, lactic acid
Type IV-def. of bracnhing enzyme:
-progressive cirrhosis of the liver
-hepatoslenomegaly in the first 18 months of life

)Gouty arthritis=punch out erosions with a rim of cortical bone
RA=narrowing of joint space+juxta articullar erosions
Gonococcal arthritis=normal joint space+soft tissue swelling
Psoriatic arthritis=marginal bony erosions+irregular joint destruction
Osteoarthritis=narrowing of joint space+osteophytes

)After placement of a central venous line=> do X-ray to check proper line placement

)In patients with family history of MEN IIa=> do DNA TESTING to identify the mutation on cromozome 10; if (+)=> do total thyroidectomy because of high risk of medullary carcinoma

)Chemotherapy for metastatic prostate cancer-with anti-androgen (leuprolide in monotherapy)+radiation

)Pseudocyesis=imaginary pregnancy because of a strong desire to become pregnant; has hormonal changes like in pregnancy, morning sickness, weight gain, changes of uterus and cervix, sensation of fetal movements, even a (+) home pregnancy test
BUT:on US-vacant uterus, pregnancy test is (-)
-treat by psychiatric evaluation

)Pertusis prevention=>give all contacts erytromycine for 14 days regardless the status of immunisation

)In exercise-induced asthma: beta-blockers+mast-cell stabilizers

)Blastomycosis south¢ral USA
-immunocompetent people
-pulmonary infection is asymptomatic or with flu-like symptoms
-cutaneous disease: verucous or ulcerative papulopustular initially, then crusted heaped-up and warthy with violaceous hue lesions, sharp borders

)Klumpke's paralysis-hand paralysis+ipsilateral Horner's syndrome
-injury of C7,C8,T1 nerves

Erb-Duchenne palsy-injury of C5, C6
-absent Moro reflex
-intact grasp reflex
-waiter's tip

Phrenic nerve injury
-injury at C3, C4, C5
-diaphragmatic+upper brahial palsy
)Acute bronchopulmonary aspergillosis
-transient pulmonary infiltrates
-peripheral Eo
-asthma
-immediate wheal and flare reaction to Aspergillus fumigatus
-brownish mucus plugs in the sputum
-high Ig E
Job syndrome-skin infections frecq. with Staph
-neutrophiles impaired chemotaxis
-very high Ig E
-treat with intermitent/continuous antibiotics

Chronic eosinophilic pneumonia-systemic signs for weeks to months
-hystory of asthma or allergic rhinitis may be present
-peripheral infiltrates negative of pulmonary edema=patognomonic
-BAL->40% Eo
-treat by steroids

Churg-Strauss syndrome-hystory of asthma treated with Zafirlukast
-fever, high Eo, with asthma becoming better
-affects: skin, kidneys, CNS, lungs, GI tract, heart
-treat by steroids+-imunosupressants

)Sinus sick syndrome-treat by ventricular pacemaker for controlling ventricular rate and type 1 antiarrythmic for atrial tachyarrythmias

)DON'T GIVE BCG TO HIV PATIENTS!!!

)In a manic patient with symptoms despite therapy=> first step check compliance with detecting Li levels...
-also get urine toxicology screen for cocaine/amphetamines

)In severe head injury (GCS=7)=>give mechanical intubation, fluid resuscitation (isotonic), sedatives and analgesics!!!

)Lidocaine-NOT used for prophylaxis of VT
-lowers the risk of VF
-increases the risk of asystole

)Patient with lung cancer and joint pains=hypertrophic osteoarthropathy

)If suspect RMSF=>start treatment, because antibodies will be (+) in convalescence

)Acute stress disroder-onset within 4 weeks from the event
-resolves in 4 weeks from onset

)If suspect intraabdominal abcess=>get CT scan of the abdomen

)In any ant-wall MI=+give heparin+3 months of warfarin due to high risk of embolism

)Because pneumococcus is resistant to penicillin/cephalosporine=> give also vancomycin
-add ampiciline (for Listeria)-in elderly and immunocompromized
-in children, give cefotaxime+ampiciline
-in hospitalized patients:ceftazidime (covers Pseudomonas)+vacomycine

)Amiotrophic lateral sclerosis=> treat by riluzole

)Metronidazole-may give disulfiram-like reactions, so avoid alcohol

)Treatment of bulimia=>antidepressants+cognitive therapy+interpersonal therapy, family therapy, group therapy

)Symptoms of GERD and (-) endoscopy=>do 24h ph monitoring

)GCA-associated with thoracic aortic aneurysm

)In trauma patient to rule out pelvic injury=> do X-ray of pelvis!!! not other complicated procedure!!!

)In drug users-Staph aureus=MCC of IE
In prosthetic valves-Staph epidermidis

)If FOBT is (+)=> do colonoscopy

)Hemochromatosis-high risk of infection wioth Listeria, but also Yersinia and vibrio vulnificus
)To diagnose MG do anti-acetylcholine antibody test, also tensillon test, but the first is currently recommended

)Kartagener's syndrome: situs inversus, sinusitis, brochiectasis

)Prinzmetal angina-avoid beta-blockers and aspirin because they increase the vasospasm

)Macrovascular hemolysis-from severly calcified aortic valves or prosthetic valves

)In HIV patient-pulmonary cavity formation from:
-TB (not if PPD<5mm)
-atypical mycobacterium
-Nocardia
-gram (-) rods
-anaerobes
-cocidioides (in SW USA)

)MS-painfull optic neuritis, central visual defect

)Treat of CHOiCE for social phobia=assertive training +SSRI
-second-lie=MAOi
-beta-blockers may help with symptoms
In adjustment disorder=>use supportive psychotherapy

)Empiema-treat by tube placement if: ph<7.2 and glucose<60mg%

)Constrcitive pericarditis-characteristic are sharp X and Y descent on central venous tracing
-in immigrant population, TB is the MCC for this disease

)Multiple fluid-filled cysts in the brain parenchyma=neurocysticercosis

)In migraines, first try NSAID, if don'twork, give triptans or ergotamine
Avoid ergotamine in:
-CAD
-HTN
-peripheral vascular disease
-liver, renal disease
-complicated migraine

)In precoucious puberty-differentiate between:
-true isosexual puberty-from activationj of the axis
-pseudo-isosexual puberty-from tumors, exogenous estrogens, severe hypothyroidism, Mc Cune-Albright
BY:GnRH stimulation test-if LH rises=>true isosexual puberty

)Congenital rubella-"blueberry muffin spots"

)Think of ruptured duodenum if free retroperitoneal air after bycicle fall

)Hypo Na(<137mEq/l)=bad prognostic factor in CHF
-it means a high level a neurohormonalo activation
-do not give high Na diet, but restrict water intake
-do not give digoxin because of reduced renal function

)Drug of CHOICE in cancer induced anorexia=Megestrol acetate

)Meningitis from Neisseria=> can go to Waterhouse-Fiedericksen syndrome and DIC

)If pregnancy is>43 weeks=> deliver; MCC of post-term dates=meconium aspiration

)Infection with resp syncitial virus=>risk of asthma later in life

)Think of PE if: new onset RBBB, FA or P pulmonale on EKG
)Folic acid deficiency:
-poor diet, alcoholism
-phenitoin-impairs absortion
-TMP/SMX, metotrexate-antagonists of dihydrofolate-reductase
)Progressive multifocal leukoencephalopathy-in HIV patients
=multiple non-enhancing lesions without mass effect in the white matter+focal neurological deficits
Primary CNS lymphoma=solitary, weakly enhancing, periventricular
-presence of DNA-EBV in the CSF is very specific
=second MCC of mass lesion in HIV patients
Toxoplasmosis-unlikely if on TMP/SMX
=ring enhancing mass lesions in the basal ganglia
-a(+) antibody titer for toxoplasma is normal in USA in normal people

)Iron supplementation-start at 6 weeks of age in all premature babies

)Quetiapine=>gives cataract
Clorpromazine=>jaundice

)Histoplasmosis-in Mississippi&Ohi river valleys
-<5% are asymptomatic
-gives an asymptomatic pulmoanry nodule

)HIGH-YIELD
Amiodarone- side effects:
-pulmonary toxicity
-thyrioid dysfunction-hypo (85%), hyper (15%)
-hepatotoxicity-raises AST/ALT transiently, but stop the drug if levels are>2 times normal
-corneal depostis
skin reactions: bluish-slate gray

)Most important factor for breast cancer is incresing age, then family hystory

)Glioblastoma multiforme-classic butterfly appearance with central necrosis

)Li maintenance therapy-life-long if >3 relapses
-for a simple manic episode-maintain it forat least 1 year

)A bronchodilator response test=> to differentiate COPD from asthma, although in some COPD there's reversibility too!!!

)If a primary siphilis is confirmed by dark-field microscopy=>no need for VDRL or FTA-ABS, but SCREEN for HIV antiboides by ELISA

)Ramsay-Hunt ataxia-generalized myoclonus, cerebellar ataxia, epileptic seizures

)Risk factors for osteoporosis: thin body habitus, smoking, alcohol, steroid use, malnutrition, family hystory, Asian or Caucasian race

)Vitamin A=>reduces morbidity/mortality of measles

)Mycoplasma=>can give erythema multiforme
-does not have a waal=>does not stain or Gram coloration
-infiltrates the lower lungs lobes

)OCP-are safe in SLE
-avoid if active renal disease present (type III in SLE)
-avoid in anti-phopholipidic syndrome
-avoid in nephrotic syndrome

)Open fractures of the foot=> don't close primarly, because of high risk of osteomyelitis
-do wound dressing+plaster cast
-do open reduction only if displaced towards planta pedis, but NOT if mildly angulated






)Waldenstrom Macroglobulinemia-hyperviscosity from very high Ig M levels
-NO RENAL PROBLEMS
-hepatosplenomegaly
-lymphadenopathy
-anemia
-low T, bleeds easily
-night sweats
-headaches,dizziness
-visual problems
-demyelinating sensory-motor neuropathy

Heavy-chain disease-like abdom. lymphoma (high Ig A)
Multiple myeloma-high Ig G or Ig A, but NOT hyperviscosity

)In mononucleosis=> get heterophileantibody test; if(-)=> do EBV specific antibody test

)Pleural PH-normal is 7.64
-empiema-<7.2
-inflamation of pleura-<7.3
-transudate due to CHF=7.35

)Buerger's disease-triad of occlusive disease of the arteries, migratory superficial trombophlebitis, Raynaud's phenomenon in a smoking young male

)Orthostatic hypoTN-in elderly:
-tolerate poorly even a mild loss of fluid (diarrhea)
-syncope after bed rest at night
-highBUN/Cr ratio

)Heparin-induced trombocytopenia=>stop heparin, DON'T GIVE LMWheparin or warfarin in exchange
-if ongoing anticoagulation is required (like in prosthetic valves)=>can give danaparoid+direct thrombin inhibitor (lepirudin or argatroban)

)Pneumovax-give in HIV patients with CD4>200/ul
-give also Hep A vaccine if they have hep B or C

Give meningococcal vaccine for splenectomized or travel exposure, not routinely

)High risk of candida in: DM, pregnancy, OCP use, immunosupression; but NOT IUD

)Dilation of ventricular system+subarahnoid space=comunicationg hydrocephalus where intraventricular hemorrhage caused subarahnoidian hemorrhage in premature babies

Dandy-Walker=cystic expansion of the 4th ventricle
Chiary malformation=pst-fossas through foramen magnum. These two are non-comunicationg hydrocephalus!!!

)Denial-a person that does not accept reality-ex.: she is told that she has breast cancer=> she goes to another doctor for a second opinion
Repression=unconcious, involuntary separation of a painful thought
ex.: she is aware of breast cancer, but she is not conciously aware ot it!
Supression-like repression, but it's a concious separation...
Dissociation=blocking emotions or thoughts from consciousness-ex.: she cries when she finds out of her breast cancer, but later she denies any memory of the event!!!

)Psoriatic arthritis-oligo-articular, asymetrical
-pitting nails
-skin rash
-arthritis mutilans
-spondiloarthropathy (sacroielitis)

)In cirrhosis, GI bleeding due to: erosive gastritis, varices, PUD, Mallory-Weis tear
-do sclerotherapy for varices only after first bleeding, NOT prophylactically
-if bleeding PUD and stopped bleeding=>conservative management; if fails=>surgery


)Fever in neutropenic patient-one reading >38.3
-or persistent readings>38 for 1h
-neutropenia<500/ul
-give empiric treatment against Pseudomonas: cefepime or ceftazidime or anti-pseudomonal penicillin+aminoglycoside
-if fever persists=>think of fungi=> add amphotericin B
-if severe mucisitis of low BP, or hystory of infection with S. aureus or Pnumococcus=> add vancomycin

)Phenitoin and carbamazepine=>can cause Steven-Johnson's syndrome or toxic epidermal necrolysis

)PKU-criteria: -Phe>20mg%
-Tyr=normal
-high urinary fenilpiruvic acid and HO-fenil-acetic acid
-normal tetrahidrobiopterin
-musty odor
fair skin, blue eyes
-eczema

)Lumbar stenosis=neurogenic claudication
-better with sitting or leaning forward
-worse with spine extension
-aggravated by walking or standing
-pain radiates to the buttocks, lower legs
-straight leg test is (-)
-degenerative changes in the vertebrae

)Treatment of acute subdural hematoma is conservative if no midline shift; otherwise do craniotomy!!!

)Epidural anesthesia=> gives hypoTN due to blood venous pooling

)Down's syndrome-Brushfield spots (speckled iris)
-hypoplasia of 5th finger middle phalanx

)Cutaneous larva migrans-dog or cat hookworm (Ancylostoma braziliense)
-by skin contact, SANDY BEACH=REMEMBER!!!
-erythematous papule that progresses with a few mm/day

)LV aneurysm-double apical beat, persistent ST elevation

)Tumor lysis syndrome-low Ca, high P, K, uric acid=HIGH YIELD

)Niemann-Pick's disease-def.of sphingomyelinase
-hypotonia,hepatosplenomegaly, cervical lymphadenopathy
-protruding abdomen
-cherry-red spot on macula

Tay-Sachs disease-def. of hexozaminidase
-hyperacusis, low IQ, no lymphadenopathy, no hepatosplenomegaly
-cherry-red spot on macula
-seizures

Gaucher's disease-def. of glucocerebrosidase
-hapatosplenomegaly, anemia, low Le, low T
-NOT involved macula

Krabbe's disease-def. of galactocerebrosidase
-hyperacusis, seizures, irritability

Mucopolysaccharidoses-course facial features, hydrocephalus, umbilical hernia

)LOW ALP-in CML, Paroxistic noct. hemoglobinuria, hypophosphatemia
Auer rods-in AML

)Rapid meningitis+skin rash=meningococcus
RMSF-does not give meningitis
)Iris nodules in neurofibromatosis are hamartomas!!!

)Aspergiloma-gives fungus ball that moves around with position change=>intermitent hemoptysis
Histoplasmosis of lung=-has calcified nodules

)To detect Meckel diverticulum: do Tc pertechnatate scintigraphy
Do angiography-for bleeding>0.5ml/min.

)Murmur of HCM-increases with Valsalva, standing, amyl nitrit, digoxin
-decreases with hand grip, leg elevation, phenilephrine

)Vit.l B12 stores of the body are available for 3-4 years, so if on vegetarian diet for only 1 year=>think of pernicious anemia as a cause for megaloblastic anemia and not low B12 levels!!!

)Epidural anesthesia=>can give urinary retention, treat it by intermitent catheterisation
-it's a transient overflow incontinence

)Chronic bronhitis-markers: prominent vascular markings, mild flattening of the diaphragm, normal DLCO, low FEV1/CV
Emphysema-has low DLCO, decreased vascular markings

)Severe pancreatitis=>give antacids to prevent stress-gastritis

)PNH-it's a RBC membrane defect=>increased binding of C=>intravascular helolysis

)Enterobius vermicularis=>treat with Albendazole or Mebendazole; second-line=Pyrantel pamoate

)Adjustment disorder-stress factor in the last 3 months, lasts reraly over 6 months from the event
-treat by psychodynamic psychoterapy
-also SSRI as adjuvant

)Catatonia-treat by Lorazepam or ECT

)Simvastatin-inhibitsHMGCoA reductase
-reduces also CoQ10=>myopathy

)Mononucleosis-can have hemolytic anemia, low T, DIC, TTP/HUS

)In a patient with renal symptoms (oliguria, high BUN, Cr)=>first do urinalysis

)Fragile X syndrome-low/normal IQ
-autism
-large head, jaw, testes, low set ears

)If parents refuse a therapy for their children=> agree with them if there's no significant harm from withholding therapy-ex. a parent can refuse vaccinations for the sons if she/he wants so!!!

)Bleeding (small) not seen on Ba enema or sigmoidoscopy=> do labeled erythrocyte scintigraphy
-NOT colonoscopy in active bleeding; if it stops, can do it!
-NOT angiography after Ba enema=>cannot see anything

)In all new diagnosed MG=> do CT scan of the chest to look for thymoma!!!

)PROM-under 34 weeks
-give steroids, no tocolysis
-deliver when fetal lungs are mature
)In parents refuse refuse treatment for their child=> go ahead with treatment or tests if it is an immediate life-threatening situation (like Hirschprung disease)
-if not life-threatening=> get court order
-consult ethics commitee only in case of dillema

)HIGH-YIELD
Theophyline toxicity-CNS stimulation (insomnia, headaches), GI problems, arrythmia
-inhibits phosphodiesterase, adenozine antagonism, stimulate epinephrine release
-if given with ciprofloxacin or eritromycin=>potential toxic effects due to higher theophyline levels!!!

)Diafragmatic hernia-after blunt abdominal trauma
-X-ray: elevation of left diaphragm, breath sounds decreased on the left side

)FA-cardiovert if unstable (100-200J); needs anticoagulation 3-4 weeks prior to that in chronic
FA-acute-cardiovert with medication (classe III antiarrythmics) or control rythm
-chronic(over 2 weeks)-control rythm beta-blockers or Ca channel blockers
-if CHF present=>use digoxin

)In PE with hemodynamic compromise and embolus in the main pulmonary artery=> do embolectomy
-DO NOT USE fibrinolitics post-op or after trauma and PE in 5 days from the event!!!

)Pulmonary contusion-after trauma
-appears in <24h
-decreased breath sounds
-hypoxemia
-CXR: patchy irregualr alveolar infiltrate, unilateral!!!

ARDS-after 24-48h from trauma and is bilateral

)Migratory trombophlebitis (Trousseau sign)=> do CT scan of the abdomen to identify the malignancy
-most patients have pancreatic carcinoma, lung, prostate, stomach, acute leukemia or colon cancers!!!
Use spiral chest CT-for PE

)PID-hospitalize if:
-fever>39
-present nausea, vomitting
-adolescents
-nulliparous
-low socio-economic status
-fail to respond to antibiotics
-pregnancy

Treat by: cefotetan+Doxi or
cefoxitin+Doxi or
clinda+genta (in pregnancy)
Outpatient give:
-ceftraxone+doxi or
-cefoxitin+probenecid

)A hystory of epilepsy or seizures is an absolute CONTRAINDICATION to Bupropion!!!

)Blastomycosis-Wisconsin, Mississippi, Ohio rivers
-chronic resp. symptoms
-fever, night sweats, weight loss
-triad: lung (cavitation), skin (papules), bone (lytic lesions)

)In age-reproductive period, if abnormal bleeding=>first do endometrial sampling and NOT GIVE estrogens!!!
-if (-) on biopsy=> can start cyclic progestins=>if fail to control bleeding=>do endometrial ablation or hyesterectomy!!!

)Clubfoot (equinovarus)-start tretment immediately: streching, manipulation, serial paster casts
-if fail=> surgery at 3-6 months of age

)If a patient is a risk for others (like in meningitis with meningococcus)=>treat against his/her wishes!!!

)In chronic asthma=>use long-term steroids for the long-term outcome!!!

)In aortic stenosis, even asymptomatic=>give IE prophylaxis
-avoidance of strenous activity=>use only in severe aortic stenosis

)Thymoma-associated with RBC aplasia
-mass in the upper mediastinum with lobulated borders


)Pap smear=>colposcopy=>endocervical curretage/ ectocervical biopsy=>cone biopsy
-if low-grade intraepithelial lesion and a strong floow-up candidate=> can first repeat Pap smear in 4 months; if still abnormal=>then do colposcopy!!!

)Hyaline membrane disease-in prematures<28 weeks
-hypoxia that does not respond to O2
-CXR:fine reticular granularity of parenchyma
-treat by ventilation +surfactant

)Alzheimer's disease-treat by donepezil, tacrine, selegeline, vit. E

)Allergic bronchopulomonary aspergillosis
-asthma like symptoms, even without hystory of asthma
-high Ig E
very high Eo
-central brochiectasis
-(+) Aspergillus skin test

)Pinealoma (germinoma)-can give Parinaud's syndrome=paralysis of vertical gaze, eyelid retraction, pupillary distrubance
-because of high beta-hCG=>stimul. of Leydig cells=>pubic/axillary hair!!!

)Paget's disease=persistent dermatitis of the nipple
-there's an underlying cancer, usually infiltrating ductal carcinoma
-proliferation of malignant cells scattered throught the epidermis (large cells with halo-like area)

)In a patient with depression or features of PTSD =>rule out hypothyroidism=>so order blood tests first!!!

)Any patient with fever, foul-smelling sputum has:
-brochiectasis or
-lung abcess or
-anaerobic pneumonia
Confirm brochiectasis=>with high-resolution CT scan (it has replaced brochography)

)Ludwig's angina=infection of the submaxillary+sublingual glands
-source of infection=teeth
-treat by penicillin+anaerobic coverage

)MEN IIa (Sipple' syndrome): high Ca, low P, high calcitonin, high ALP

)Preterm labor-<37 weeks
-contractions
-cervical efaccement>80%
-cervical dilation of>2cm
Treat-first by bed rest+hydration=>it inhibits oxytocin; if it fails=>give tocolysis

)Patients have the right to know their diagnosis; if a family member pleads not to tell the patient=>first explore the reason for this!!!

)COPD-exacerbation=>give albuterol+ipratropium+systemic steroids

)Cold leg after MI-confirm it by angiography=>do embolectomy

)In UC=>do colonoscopy after 8 years from diagnosis with 4 biopsies every 10cm from ceccum to rectum

)Olanzapine-gives obesity, but NOT dystonia

)In comunity-acquired pneumonia (even in COPD)=>give new fluorokinolones (levo or gatifloxacin)
-outpatient: give azytromycin or Doxi

)Hypertrophic dystrophy of vulva-post-menop
-do biopsy to diagnose it
-give flouorinated corticosteroids for 6 weeks

)Treatment for re-coarctation of aorta=balloon angioplasty; use surgery for primary coarctation

)Methylphenidate-gives decreased apetite, weight loss, abdom. pain, insomnia
-don't use under 6 years of age

)In ventilation problems post-op=>calculate A-a gradient
If high=>think of shunt or V/Q mismatch (normal is 5-15)
Shunt in: pulmonary edema, intracardiac (ASD, VSD), atelectasis...

)Barlow's maneuver-to see if a hip is dislocatable
Ortolani's maneuver-to see if a dislocated hip is reducible
-use US under 6 month for diagnosing hip displasia

)Vasovagal syncope-use upright tilt-table test to confirm the diagnosis

)If decreased fetal movements=>do NST
-MCC is sleeping baby, so use vibratory stimulation to wake him up
-if still (-)=> do BPP

In CST-if late decelerations are present=> deliver; if only one late deceleration=>suspicous, repeat next day

)In massive hemoptysis=>CHOICE=rigid brochoscopy

)Pneumomediastinum with tensio pneumotorax=>responds to chest tube drainage
Pneumomediastinum with mediastinitis=>surgical drainage of the mediastinum

)Triad=hyperglicemia, migratory necrotizing dermatitis, weight loss=GLUCAGONOMA!!!

)DUB after menarche or before menopause (physiologic)=>give estrogen=CHOICE for 1-25 days and medroxyprogesterone for the last 10-15 days, then 5-7 days give nothing to allow for withdrawl bleeding

)Tamoxifen-increases risk of endometrial cancer and uterine sarcoma

)Chorioamniotitis-maternal fever, uterine tenderness, fetal tahicardia (may be also from beta2 agonists), high Le(may be also from steroids)
-give ampi+genta, then deliver

)Fetal distress (late decelerations)=indications for delivery by emergent C. section, especially if small fetus and early stage of labor

)Non-comunicating hydrocele-=>observation
-can palpate the upper limit of the testicle
Comunicating hydrocele-upper limits of testicle cannot be palpated=>treat surgical

)Stress incontinence-in multipara
-post-void residual volumem is normal
-treat by estrogen replacement (post-menop.), kegel exercises, pessaries, surgery (Burtch or Sling procedures)

)Jaundice that appears >3rd day to 1st week of life=>suggests bacterial sepsis or UTI
-do-blood cultures+lumbar puncture

)Airway is secure in apatient who can talk=> no need for intubation even if after MVA
-but if tahipneic, nosy respiration=>chinlift and give O2 by mask

)Zidovudine-give orally to the newborn for 6 weeks after birth from HIV mother
-give orally to the mother in the 1st trimester and iv. durin labor/delivery

)PKU-RA disease
-do Guthrie test (qualitative) for Phe metabolits in the urine

)If pregnant woman does not want C. section=> don't do it since the fetus is a part of her body and you cannot oblige her, even if you think tht this is the right thing!!!

)In placenta abruotion, use C. section only if fetal/maternal deterioration or early stage of labor
-if everything is fine=> allow vaginal delivery

)Patient over 15 years of age=> no need for parental consent if she wants OCP, treament for STD or drug abuse!!!

)Isolated duodenal hematoma=>treat conservatively by NG suction+parenteral nutrition

)Inflamatory aspect of Pap smear: ASCUS=atypical squamous cells of undetermined significance=>repeat Pap smear 4-6 months later

)Beckwith-Wiedermann=macrosomia, neonatal hypoglicemia, hyperinsulinemia, macroglosia, omphalocel, visceromegaly, characteristic earlobe crease
-very high risk of Wilms tumor, hepato/gonadoblastoma
Over 2 yearsof age=>DON'T THINK of Pathau or Edwards syndromes=>they are dead already!!!

)In major renal laceration+blunting of psoas shadow+ULQ tenderness (spleen) from trauma=>do CT scan with contrast!!!

)Diamond-Blackfan anemia-congenital hypoplastic anemia
-pure red-cell aplasia, shielded chest, triphalangeal thumbs, short stature, webbed neck, cleft lip

)If a minor (ex. 17 years) needs surgery (for appendicitis)=>contact her guardian (parents usually)

)Central cord syndrome-from hyperextension injuries
-weakness more in the upper extremities

)In case of child abuse=>first do a complete physical examination, then in order:
-skeletal survey
-coagulation profile
-report to child protectiove agencies
-admit if necessary
-consult psychiatrist/explore family dynamics

)In clavicle fracture, if a bruit is heard=>first do angiogram

)To confirm Duchenne muscular dystrophy=>do DNA studies, not muscular biopsy anymore!!!

)Hypocondriasis-discuss current emotional stressors+brief psychotherapy
-symptoms become prominent in periods of stress

)Excision therapy in burns-for extensive partial/total thickness burns
Mafenide sulfate-only for deep penetration, required in an eschar

)Poat-partum=>lochia rubra=>in 3-4 days lochia serosa=>white=>yellow; if foul-smelling=>think endometritis; high Le are normal post-partum

)Turner' s syndrome with 46, XY=>increased risk gonadoblastoma=>prophylactic gonadectomy
Webbed neck is due to channel lymphatic channel abnormalitiess

)Biliary colic-no Murphy's sign, no fever, no high Le
-no need for hydration or antibiotics
-give spasmolytics+analgesic therapy

Gas in the gall-bladder+calculi- are due to papilosphincterotomy

)Endometritis-due to anaerobs and aerobs=>give clinda+ampi/genta

)Mild metatarsus adductus-no treatment
-the same is valid for internal tibial torsion

)Torus palatinus-benign bony mass on the hard palate
-fleshy mobile/immobile mass in young people
-no therapy required

)Benign glucosuria of pregnancy=>get fasting urine glucose to rule out GDM

)MC factor of female infertility is peritoneal factor!!! (endometriosis, peritoneal adhesions)-wired, BUT THIS IS WHAT THEY SAY!!!
)In a childwith reccurent URI and bilat. nasal polyps=>rule out cystic fibrosis

)Minor over 13 years of age, emancipated=>no need for parental consent
-if in the army, married, pregnant, has children, financially independent

)Bowel obstruction (if no perforation suspected)=>conservative management with fluids, NG suction, enemas

)Septic abortion-hystory of recent abortion+fever, chills,abdom. pain, vaginal discharge
-treat by gentle suction curettage, cervical and blood sampling for cultures, iv. antibiotics

)MC peripheral artery aneurysm=popliteal, then femoral!!!

)Zavanelli maneuver-in shoulder dystocia, push back thebaby in the uterus, followed by C.section

)Spondylolisthesis-several months of back pain and neurologic dysfunction (bed wetting)
-palpable "step off" at the lumbosacral area
-forward slip of vertebrae (L5 over S1 frecq.)
-in preadolescent children

)Give patients a COPY of their records, NOT the original!!!

)Increased oxalate absortion-in bowel resection
-tea drinker, chocolate intake, beer, coffee, ethylene glycol poisoning

)Growth of only axillary hair=premature adrenarche
Premature thelarche or adrenarche=>no clinical significance
Premature pubarche=>thourough evaluation (50% are CNS disorders)

)WAGR syndrome-Wilm's tumor, aniridia, mental retardation, genitourinary anomaly

)In any apneic patient=>intubation or surgical cricothyroidectomy

)Acute bacterial sinusitis=clinical diagnosis, start amoxi

)Bereavement-has symptoms of major depression, but lasts less than 2 months

)Gaucher's disease-in Askenazi jews
Gaucher cells-wrinkled paper appearance
-bone pain-on x-ray: Erlenmayer flask deformity of distal femur

)In an emergent situation, if patient is uncouncious=> go ahead with life-saving treatment if there's no prior information from the patient about his religious beliefs (even if his wife says so, it doesn't matter what she says)

)Infarction of the bowel=early complication of operation on abdominal aorta
-pain, bloody diarrhea
Aorto-enteric fistula-takes months to years to develop
)In hypergonadotropic hypogonadism-increased FSH, absent breasts, primary amenorrhea, no pubic/axillary hair
-get karyotype:
-45,XO=Turner
-ovarian resistance syndrome-46,XX
-46XY syndrome
-Savage syndrome
-def. of 17 alpha hydroxylase or 17, 20 desmolase (46,XY)

)Down's syndrome-endocardial cushion defect of AV canal
-absence of septum=>L to R shunt=>loud P2

)Conversion disorder-paralysis that improves after sodiumamytal (amobarbital)

)Elderly with displaced femoral neck fractures=>primary arthroplasty
Garden classification:
-type 1-valgus impaction of femoral head (in stress fractures)
-type 2-complete, but non-displaced fracture of neck
-type 3-complete, displaced<50%
-type 4-complete, displaced>50%
)PCOS-has insulin resistance=>:get 2h glucose tolerance test>140mg%
-treat by life-style modifications+metformin to prevent DM type II
-metformin corrects the obesity by giving anorexia, correct hirsutism, with clomiphene stimulates ovulation
-it's an alternative to OCP for restoring ovulatory menses when OCP are contraindicated!!!

)Fracture of scaphoid-treat by 6-12 weeks of cast immobilisation if no displacement or under 2mm and no angulation
-if displaced: open reduction+internal fixation

)Pelvimetry-do it in hystory of vaginaldelivery for breech, pelvic abnormalities, trauma of pelvis; but NOT in cephalic presentation in primiparous women

)In 2-5 years age period=>think opf Wilms tumor
Under 1 year=>think of neuroblastoma

)Granuloma inguinale-Donovania granulomatis
-occur in 1-12 weeks after inocculation
-painless ulcers with irregular borders and a beefy-red granular base
-Donovanian bodies: on Giemsa or Wright’s stains-reddish, encapsulated, bipolar staining bacteria found within monocytes
-treat byTetracycline for 10-21 days

)A PPD>10mm in asymptomatic immigrants=>get chest X-ray; if (-)=> do nothing; if(+)=>give IHN+vit. B6
If active TB in pregnancy=>treat with combination of drugs except streptomycine

)Meningitis=> can give regression of developmental milestones

)A patient in hypovolemic shock from accident=> do Abdom. US or DPL; NEVER=Laparoscopy!!!

)Tricuspide atresia-cyanosis, left axis deviation
-must have VSD or ASD or PDA
-holosystolic murmur
-decreased vascular markings
-normal heart size
-single S2

)Absent bowel sounds and gaseous distention of BOTH small and large intestine=paralytic ileus

)Radiation levels from diagnostic exams=>have no teratogenic effects because they are in very low doses!!!

)Cardiac contusion from accidents=> check EKG for possible arrhythmia

)If prolonged latent phase in pregnancy=> therapeutic rest of try oxytocin
If arrest in active phase=> do C. section

)Pancreatic abcess=> do external drainage
Pancreatic pseudo-cysts=> do internal drainage or ERCP or treat conservatively (if <5cm and <6 weeks old)

)Retinal hemorrhages-in preeclamsia is a SEVERE sign=> because it very likely that damages occurred in other organs too!!!

)Fracture of clavicle at the junction of medial 2/3 with external 1/3=> figure of 8 bandage for 6 weeks

)Amniotic fluid embolism-complication of amniocentesis or labor
-purpuric rash
-respiratory failure, cyanosis
-seizures, low BP, DIC
-treat by: fluids, but FIRST=INTUBATE if O2 sat is 75% or below, on 100% O2 given by face mask!!!

)Perforation of oesophagus after biopsy=> do contrast study of oesophagus with water-soluble contrast; NOT endoscopy=>it may further damage the perforation

)Threaten abortion=> do reassurance and follow-up

)If suspected IUGR=> get abdominal circumference on US to estimate fetal weight

)Injuries of duodenum=>retroperitoneal air=> confirm by upper CT scan with oral contrast or upper GI study with gastrografin

)Post-seizures paralysis=Todd’s paralysis, resolves in 24h
After seizures=> post. dislocation of the shoulder

)Dysmenorrhea+ heavy menses+ enlarged uterus=either adenomyosis or fibroid uterus

)In post-strep GN:
-low C3 comes back to normal in 8-12 weeks
-hematuria may persist 6 months
-proteinuria may persist 3 years
-ASL -peak in 1 month and come back to normal in 3-4 months

)Amputated finger=> wrappe it in saline-moistened gauze sponge, place this in a plastic bag and the bag on ice; DON’T PUT the finger on ice directly!!!

)MCC of ambliopia=strabismus
-treat by covering the normal eye!!!

)FIRST response to hypovolemic shock is TAHYCARDIA, then vasoconstriction, then low BP, high respiratory rate and altered consciousness

)HELLP syndrome=> deliver if >34 weeks of gestation
Major cause of death in eclamsia= hemorrhage stroke

)Basillar skull fracture=> first rule out head injury by CT scan, then expectant therapy=RULE for uncomplicated basillar skull fracture

)Children with parental hystory of elevated cholesterol (>240mg%) => get screening test for total cholesterol=> if >200mg% do fasting lipid profile

)Prolonged latent phase-in primipara>20 h
-in multipara>14h
-in twins=> the cause is hypocontractile dysfunction= give oxytocin
-in hypertonic contractions from prior oxytocin or exccessive anesthesia=> give therapeutic rest

)Supracondillar fractures=> injury to the brachial artery

)Huntington’s corrhea=> chromosome 4

)Turner’s syndrome-may be 45XO or 46XY (here risk of gonadoblastoma)
-streak ovaries, not visible on US
-keloids
-hearing loss, glucose intolerance, HTN
-very high FSH>high LH

)Sturge-Weber’s syndrome-occurs in sporadic fashion (not mendelian)
-a cerebral lesion is found on the same side of the facial nevus
-buphtalmos (congenital glaucoma)
-cerebral lesions=nevi in the leptomeninge, hystologically similar to the facial ones

)Hystory of trauma to the foot and crunching=> may be fracture of metatarsal bones
-pain on walking, not at rest
-pain on passive motion of the foot and dorsiflexion=pain in the middle of the foot
-occurs after a fall from height
Stress fractures or tenosynovitis occur after prolonged exertion

)Mesenteric thrombosis-severe abdom. pain, may radiate to the back
NOT controlled with analgetics, Bloody Diarrhea, (+) Murphy sign, CVA tenderness, mottled cyanosis of the flanks, low BP, high RR
In acute pancreatitis => NO bloody diarrhea


)Midpelvis contraction=arrest of dilation,due to prominent ischial spines
a fetus at station +1 is already engaged, so there’s no inlet dystocia
Anesthesia in the latent phase=>decreases the strengh of uterine contractions
-in the active phase however=> no effect on uterine contractions

)Mc Cune Allbright syndrome-defect in protein G-AMPc kinase function
-precocious puberty, café au lait spots, polyostotic fibrous dysplasia, low IQ

)Signs of aortic rupture=>most reliable are: wide mediastinum>8 cm and obliteration of aortic knob
-screen with chest X-ray, confirm with CT spiral or angiogram

)In burns-apply rule of 9s or rule of palm=1% of body surface (the palm of the patient, not yours!!!). These are used for calculating the volume of fluids that will be given. DON’T take into account first degree burns, BUT only second+third degree burns!!!

)L-Tyroxine does NOT cross the placenta, but TSI DOES and remains elevated a few months after Graves disease surgery=> gives thyrotoxicosis in neonates!!!

)Prolonged latent phase-causes:
-hypertonic uterine contractions=> give morphine and bed rest
-hypotonic uterine contractions (twins)=>give oxytocin
-premature or excessive anesthsia or sedation=> allow the drug to be excreted
Remember: FALSE LABOR=NO CERVICAL CHANGES!!!

)In hemothrax=> do surgery if on chest tube bleeding >1500ml in total or >600ml in 6h after chest tube placement

)Variceal bleeding and 5 or more blood units are needed in 24h=>do surgery (TIPS)
-if <5 units of blood used, keep Sandstaken-Blackmoore tube for another 24h (total 48h)

)Intestinal obstruction-if simple=> gives metabolic alkalosis from vomitting, BUT IF there’s compensated acidosis like:
ph=7.36
HCO3=15
pCO2=28 and compensated shock: HR=120/min., RR=30/min, BP=110/80mmHg=>THINK OF BOWEL ISCHEMIA=>DO LAPAROTOMY, even if there’s no abdominal guarding!!!

)Fetus: HR=110/min , BP= 90/60mmHg=>is unstable=> DO C. section what are you waiting for???

)In cogenital diaframatic hernia=> first place orogastric tube to scution out=> prevents further lung compression; then do Chest X-ray

)To screen for GDM=> 1h glucose tolerance test; if >140mg%=> do 3h test; if>200mg%on this=> we have a GDM patient

)Scarlet fever-treat of CHOICE is Penicillin V

)If hyperemesis gravidarium persists beyond the 1st. trimester=>check beta-HCG and then to US of pelvis (think of hydatiform mole)

)In Zollinger-Ellison syndrome, high acid inactivates pancreatic enzymes=> steatorrhea!!!

)If trip in 1 week to endemic areas=> give Hep A IG, because vaccine will take up to 1 month to be effective!!!

)Young smoker with sudden chest pain=> think pneumotorax=> get chest X-ray

)In non-compliant patient with schizofrenia=> give flufenazine (long-acting drug, injectable) or haloperidol-2/month

)De Quervain tenosynovitis-tenderness over the radial side of the wrist and first dorsal compartment
(+) Finkelstein maneuver=> treat with local injection of long-acting steroids

)Paroxistic norturnal hemoglobinuria-defect in decay accelerating factor

)Recurrent TV and low EF being on diuretics=>check electrolytes as a cause


)Virilizing neoplasm-test=>check testosterone and DHEA
-if testosterone is normal and DHEA is high=adrenal source; then check 17HO progesterone to rule out late onset CAH (may have normal menstrual cycles)
-if testosteron is elevated and DHEA is normal=ovarian source

)Whipple’s disease-arthralgia, generalized adenopathy, skin pigmentation, chronic diarrhea, weight loss=> do small bowel biopsy for confirmation

)Transplant dysfunction-early post-op-causes:
-acute rejection
-cyclosporine toxicity
-ureteral obstruction
-vascular obstruction
-acute tubular necrosis

)In febrile neutropenia, even with severe anemia and trombocytopenia=>FIRST get blood cultures and START cefepime or ceftazidime

)Primary sclerosing cholangitis-occurs in UC
-on cholangiography: beading due to strictures and dilation of intra/extrahepatic ducts
-hypergamaglobulinemia (high IgM)
-pANCA (+)
-auto-antibodies (+): ANA, anti-SMA, anti-cardiolipin
-may have (+) rheumatoid factor

)In penicillin allergic patients with syphilis=>give DOXI or Tetracycline NOT Erythromycin

)Spiking fever 7-10 days post-partum and (-) pelvic ultrasonogram (excludes an abcess)=>give Heparin for Thromboflebitis!!!

)Pyloric stenosis=>first give iv. hydration+ K replacement; then do surgery!!!

)Parvovirus infection-joint involvement is symmetrical in hands, wrists, knees, feet+morning stiffness of aprox. 15minutes
+/-rash
-study of choice=detect anti-B19 IgM antibodies-develop in 10-15 days
-if persist more than 6 months=>chronic infection
-anti-B19 IgG (+) without IgM=>past infection

)Monteggia fracture=fracture of proximal 1/3 of ulna+ant.dislocation of radial head
-treat: open reduction+internal fixation
Galeazzi fracture=isolated radial shaft fracture+disruption of distal radio-ulnar joint
-treat: the same as above

)Heat exhaution-volume depletion under heat stress
-body temperature<40
-lack of CNS symptoms (these are present in heat stroke)

)In an old patient with voiding symptoms and non-bacterial prostatitis=>first rule out bladder cancer by urine cytology and cystoscopy!!!
Give: -TMP/SMX for chronic bacterial prostatitis
-Erythromycin for non-bacterial prostatitis (may be caused by Mycoplasma or Ureoplasma)
-Torazosin for protatodinia

)Autoimmune hemolytic anemia-may have all of the following:
-spherocytes, negative family hystory, (+) Coombs test, (+) osmotic fragility test, high LDH, Bilirubin, reticulocytes, splenomegaly

)CMV Colitis in HIV patients:
-bloody diarrhea, abdom. pain, multiple ulcers/erosions of colic mucosa
-on biopsy: cytomegalic cells (large cells) with eosinophilic intranuclear and bazophilic cytoplasmic inclusions (Owl’s eye effect)

Cryptosporidium=> gives watery diarrhea

)Patient on warfarin and he is bleeding=>FIRST give FFP, then vitamin K

-if INR<5=> omit NEXT DOSE ofWarfarin
-if INR:5-9 and no significant bleeding=> stop Warfarin temporarily
-if INR>9=>STOP Warfarin, give orally Vit. K

)If contractions are present but NO CERVICAL CHANGE=FALSE LABOR=>conservative management and NO TOCOLYSIS!!!

)COPD with acute symptoms of infection+opacification of a hemithorax on X-ray=>do URGENT bronchoscopy to remove mucus plug (cause of obstruction)

)In CREST syndrome=>hardening of skin is limited to the face and hands
In scleroderma (diffuse)=>it involves the trunk+proximal extremities

)At 35 years of age=>do baseline mamogram. DO IT FIRST even there’s a mass like fibroadenoma present

)The cause of metabolic alkalosis in vomitting is CHLORIDE DEPLETION, because it stimulates HCO3 renal reabsortion

)To screen low risk populations (athlets) for cardiac disease=> just get medical hystory+physical examination; NOT EKG NOR ECHOCARDIOGRAM

)VIP-oma=pancreatic cholara
-diarrhea, leg cramps (from low K), abdom.pain, weight loss, dehydration
-abdominal mass on CT

)Total abdominal hysterectomy=BEST Choice for Uterine Rupture
-if pregnancy is still desired=>just close the site of rupture!!!

)Ileus meconial=>What are you thinking first??? Cystic fibrosis of course-mutation of genes on cromozomes 7-deletion of a 3 base pair (DA508)

)Endometriosis-gold standard is LAPAROSCOPY
-may give hemorrhage into the ovaries=cystic cavity filled with blood with dark brown color=”chocolate cyst”

)MCC of leukoria (white reflex)=congenital cataract, NOT Retinoblastoma
Congenital cataract-may be from galactosemia, Down or Turner’s syndromes, TORCH infections, long-term/high doses of steroid treatment

)PROM with fetus with renal agenesis=>incompatible with life=>deliver vaginally (NO NEED FOR C. section, since the child will die anyway)!!!

)Cephalhematoma-involves one bone
-subperiostal hemorrhage
-limited to the surface of one bone
-no discoloration of the overlying scalp
-swelling not visible at birth, but after several hours
-will resorb itself in 2-3 months

Caput succedaneum-diffuse, echimotic swelling of the scalp, across the midline and suture lines

)IUGR-deliver if >34 weeks and fetal lungs are mature
-if olygohydramnios is also associated=>deliver at any age!!!

)Mongolian spots:
-bluish discoloaration, bluish-gray or bluish-green or blue-black flat skin markings that appear at birth
-don not fade into the surrounding skin
-fade in a few years, NO treatment needed

)Shoulder dystocia=common cause of clavicular fractures in gestational DM with large babies
-usually NO Treatment required

)Tamoxifen-is antiestrogenic
-overall mortality is decreased with its use despite the small risk of endometrial carcinoma
-women develop hot-flashes and vaginal dryness from it (Tamoxifen)
)Local impetigo-give topical mupirocin or oral erythromycin

)In an advanced stage of premature labor (like in active phase)=>give tocolysis (MgSO4=CHOICE), bed rest, get cervical cultures and give antibiotics even ROM have not occurred yet; also give steroids if between 24-34 weeks of gestation

)Asymptomatic bacteriuria of pregnancy=>give 7-10 days of nitrofurantoin or ampi or first-generation cephalosporine
-NOT: TMP/SMX NOR CIPROFLOXACINE

)Before 37 weeks and fetus in breech=> DO NOTHING, it may convert to vertex by itself
-after 37 weeks=>do external cephalic version BEFORE the ONSET of Labor

)Lymphogranuloma venereum-gives inguinal adenitis in the second stage=> “groove sign”
-in men: superficial+deep inguinal lymph nodes involved
-in women: deep nodes of rectum and anus=>may lead to Proctocolitis, Stricture, Fistula (recto-vesical) or Elephantiasis
-treat by: Tetra pr Erythro for 2-3 weeks or Doxi or TMP/SMX
 
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